The American College of Allergy, Asthma and Immunology released an update on Oct 1, 2013: Egg Allergic Children Now Have No Barriers to Flu Shot
The following is a blog post from KFA's Medical Advisory Team from 2012:
2012 UPDATE ON EGG ALLERGY AND THE FLU VACCINE
by Matthew J. Greenhawt, MD, MBA, MSc
Much has changed regarding the perceived safety of influenza vaccine in egg allergic individuals. The Centers for Disease Control (CDC) no longer considers egg allergy a contraindication to receiving an influenza vaccine. This is based on several research studies conducted in recent years, which conclusively show the injectable influenza vaccine is safe for children with egg allergy.
The American Academy of Allergy, Asthma, and Immunology (AAAAI) and the American College of Allergy, Asthma, and Immunology (ACAAI) have updated the national practice parameter on this topic twice in the past 3 years, most recently this past summer. The Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control updated its recommendations in August of 2012. Though the AAAAI/ACAAI and the ACIP recommendations differ slightly, the main points are largely the same:
- Skin testing to the vaccine is no longer advised, and is not necessary to receive the vaccine. Several studies have shown that this does not help predict who will develop a reaction to the vaccine, even when the skin tests are positive.
- While either a single dose or a two-step graded challenge are acceptable ways to vaccinate egg allergic individuals, a single dose has been shown to be safe even in children with a history of anaphylaxis to egg, Therefore, the use of two-step graded challenges are not necessary, though many providers likely will continue to use this method.
- The amount of egg (ovalbumin) in influenza vaccine is low and has been for the past several years. A 1997 study did note that vaccine ovalbumin content below 1.2 micrograms/mL was well tolerated in egg allergic individuals, and has since served as a “de facto” safe level. Furthermore, this “safe” level was not a designed outcome of the study, and represented what the level of ovalbumin in the vaccine happened to be in the lots used in the study. Ovalbumin in influenza vaccine has never directly been attributed to causing reactions in egg allergic individuals. There is recent data that has shown higher ovalbumin levels were well tolerated. However, all presently marketed injectable influenza vaccine for use in the US contain less than 1.2 micrograms/mL, and this argument is no longer of clinical relevance. The CDC has published this information in August of the past two years. Though Sanofi Pasteur’s Fluzone was not included in those publications, through personal communication with Sanofi, the company has verified that Fluzone’s ovalbumin content is under 1mcg/mL
- There is now data supporting that ALL egg allergic patients can safely receive their influenza vaccine, regardless of how severe their egg allergy was in the past. This includes children with anaphylaxis to egg. Moreover, a very recent study has shown that children with severe egg allergy can receive their influenza vaccine as a single dose, as opposed to a two-step graded challenge.
The latest guidelines from the CDC were updated in August 2012 and were unchanged from August 2011. These recommend that children with a history of developing only hives after egg ingestion can receive the vaccine at the pediatrician's office. If the egg reaction was more severe, these children can still get the vaccine, but at an allergist's office.
Some additional important points:
- The safety of the intranasal spray form of the vaccine, known as Flumist, in egg allergic children is still being evaluated. The CDC recommends that egg allergic individuals only receive the injectable vaccine.
- Children with an egg allergy can receive the injectable flu vaccine, but it needs to be done in a pediatrician’s office or an allergist’s office (depending on the egg allergy severity) rather than in a minute clinic, health department clinic or pharmacy.
- If your child has a history of reaction to the vaccine itself, this is a different scenario than someone with a history of egg allergy but has not ever reacted to the flu vaccine. Children who have reacted to the actual vaccine should be evaluated by a board certified allergist to determine if it is safe for them to receive the vaccine in the future.
- The package inserts for the influenza vaccine will still have the original wording regarding contraindications with egg allergy, even though the CDC recommendations now state it’s safe to administer to children with an egg allergy in a pediatrician’s or allergist’s office.
In conclusion, the thinking on the topic of the safety of the administration of the influenza vaccine for egg allergic individuals has changed significantly. Importantly, egg allergic individuals wanting to receive injectable influenza vaccine can do so. The vaccine is no longer contraindicated because of egg allergy, and the vaccine is safe even if there has been a severe past reaction to egg. Either your pediatrician or your allergist (depending on the egg allergy severity) can provide the flu vaccine.
Matthew Greenhawt, MD, MBA, MSc, is assistant professor, Department of Internal Medicine, Division of Allergy & Clinical Immunology and the University of Michigan Food Allergy Center, University of Michigan Medical School and University of Michigan Health System Ann Arbor, Michigan. He is a member of KFA’s Medical Advisory Team. He is co-author of the 2011 special practice parameter update on the safety of influenza vaccine in egg allergic individuals, and co-author of the 2012 practice parameter on adverse reactions to vaccines.