Reviews and feature article
Administration of influenza vaccines to patients with egg allergy

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How frequent and severe are allergic reactions to influenza vaccines?

Anaphylactic reactions to influenza vaccines are exceedingly rare; however, it must be acknowledged that patients with egg allergy are typically excluded from influenza vaccination, which could account for the low rate of reported reactions. In 1976, the Center for Disease Control and Prevention coordinated nationwide surveillance for illnesses after influenza vaccination. Only 11 cases of anaphylaxis were reported out of 48,161,019 persons immunized (1 case per every 4.4 million vaccinees),

What do published studies say about the safety of administering influenza vaccines to patients with egg allergy?

James et al7 administered influenza vaccine to 83 children and adults with egg allergy (median age, 3 years; range, 1-46 years) and 124 control subjects without egg allergy. The group with egg allergy all had positive egg skin test results and convincing histories of clinical reactions or positive blinded challenge results to egg, including 27 patients with “a convincing history of anaphylaxis including generalized urticaria, wheezing, laryngeal edema, and/or hypotension.” Only 4 of the

How much egg protein is in influenza vaccines?

Influenza vaccine might contain several egg white proteins, including ovomucoid, ovalbumin, and conalbumin. Manufacturers and independent research laboratories report ovalbumin content because ELISA assays are available to measure ovalbumin and ovalbumin reflects the amount of egg white protein in the vaccine. At the time the James et al study7 was published in 1998, influenza vaccine manufacturers did not state the ovalbumin content of their vaccines. More recently, all but 1 manufacturer of

Are there published protocols on how to administer influenza vaccine to patients with egg allergy?

A number of published studies have advocated various approaches to the administration of influenza vaccines in patients with egg allergy.7, 10, 11, 12, 13 Some involve skin testing with the vaccine (skin prick testing at full strength with or without subsequent intradermal testing with the vaccine diluted 1:100). Based on the results of the skin testing, the vaccine is either withheld or administered in divided doses. Some involve administration of the vaccine as a single dose, whereas others

Is it time for a less conservative approach?

Although skin testing is an appropriate method to evaluate allergic reactions to vaccines,14 it might not be required in the specific case of administering influenza vaccines to patients with egg allergy. Such patients have a history of reacting to the ingestion of eggs, which should be confirmed by means of skin testing or in vitro assay for specific IgE antibody to egg at the time of influenza vaccination to see whether the egg allergy has resolved. However, such patients typically have no

Editorial opinion

Patients with egg allergy for whom influenza vaccine is indicated can and should be vaccinated to decrease the morbidity and mortality associated with the disease. Based on available data, consideration can be given to administering a vaccine with a stated ovalbumin content of less than 1 μg per 0.5-mL dose (Table I) as a single dose without prior vaccine skin testing. Such immunization should take place in a setting in which personnel and equipment are available to recognize and treat

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Disclosure of potential conflict of interest: J. M. Kelso has declared that he has no conflict of interest.

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