Recommendations for administering the triple viral vaccine and antiinfluenza vaccine in patients with egg allergy

Actually, food allergy is an emerging pathology; and egg allergy is the most frequent in childhood. The recommendations for measles, mumps and rubella (MMR) and influenza vaccination are increasing each year. This implementation increases the exposure of patients with egg allergy to such vaccines. In Spain, since 2004 the only available vaccine for MMR is grown in cultures of fibroblast from chick embryos; previously, patients with egg allergy were vaccinated with an alternative vaccine cultivated in diploid human cells which is no longer commercialized. Influenza vaccines grow in chick egg and the final product contains egg proteins (large variation in egg protein content has been reported). As controversy exist, the Food Allergy Committee of Spanish Society of Clinical Immunology and Pediatric Allergy decided to report some recommendations for the safe administration of MMR and influenza vaccines in patients with egg allergy. In summary, MMR vaccine is safe for children with egg allergy, only in patients with severe anaphylactic reaction after egg ingestion is recommended the administration in his reference hospital. Influenza vaccine is contraindicated in patients with severe anaphylactic reaction after egg ingestion. The rest can receive influenza vaccine in a 2-dose protocol with a vaccine that contains no more than 1.2 mcg of egg protein for mL.     

Allergies et vaccins

Atopy and the onset of an allergic reaction during vaccination sometimes result in abstention that disadvantages the patient. First, the problem of vaccinating the atopic individual is discussed with the recurrent problem of egg allergy. Only severe anaphylaxis to egg requires hospitalization for vaccines containing egg protein. Asthma exacerbation reactions or atopic dermatitis (flash phenomenon) require certain precautions before vaccination. Apart from these measures, there is no systematic vaccine contraindication for the atopic child and the French vaccination schedule can be applied to children with allergies. After reviewing the components of vaccines that have an allergic potential, we discuss the course to follow in cases of reaction to a vaccine.     

Safety of measles-mumps-rubella vaccine (MMR) in patients allergic to eggs

IntroductionSince the measles and mumps components used in MMR vaccine are grown in cultures of fibroblast from chick embryos, for a long time there have been concerns about the presence of egg protein in the vaccine and the recommendations given to egg allergic patients.We include in this paper our clinical experience vaccinating egg allergic patients with a regular triple viral vaccine, as well as an immunological study of each vaccine available in Spain. The aim of this study was to evaluate the clinical safety of a conventional MMR vaccine in a population of egg allergic patients and to determine the presence of egg allergens in a conventional MMR vaccine and if IgE antibodies from egg allergic can recognize egg allergens in this vaccineMaterials and methodsChildren 15 months old with a confirmed diagnosed of egg allergy were included.In all patients, a skin prick test with non diluted MMR vaccine (Priorix, GSK) was made.If negative, each patient received a single dose of measles, mumps, rubella (MMR) vaccine. If positive, a fractionated injection of the vaccine was made following SEICAP recommendations (2004).SDS-PAGE immunoblotting was performed with Priorix vaccine.ResultsA cumulative total of 26 patients with egg allergy have safely received MMR vaccine in a single-dose (after a negative SPT in all cases) at our department without any reaction.5 sera of vaccinated patients and 6 control sera of egg allergic patients (positive oral challenge) were used to immunolabel the membranes. No positive bands corresponding to egg proteins were found in any of the patients.ConclusionNegative results found in SPT support the absence of clinical reaction against the components and Immunological studies point that there is no detectable amount of egg protein in this vaccine to produce an IgE mediated reaction. We can conclude that MMR can be safely administrated in children allergic to egg.     

Allergy to COVID-19 vaccines: A current update

Adverse allergic reactions due to the administration of the vaccines developed for the protection of coronavirus disease 2019 (COVID-19) have been reported since the initiation of the vaccination campaigns. Current analyses provided by the Center for Disease Control and Prevention (CDC) and Food and Drug Administration (FDA) in the United States have estimated the rates of anaphylactic reactions in 2.5 and 11.1 per million of mRNA-1273 and BNT162b2 vaccines administered, respectively. Although rather low, such rates could have importance due to the uncommon fact that a large majority of the world population will be subjected to vaccination with the aforementioned vaccines in the following months and vaccination will most likely be necessary every season as for influenza vaccines. Health regulators have advised that any subject with a previous history of allergy to drugs or any component of the vaccines should not be vaccinated, however, certain misunderstanding exists since allergy to specific excipients in drugs and vaccines are in occasions misdiagnosed due to an absence of suspicion to specific excipients as allergenic triggers or due to inaccurate labeling or nomenclature. In this review, we provide an updated revision of the most current data regarding the anaphylactic reactions described for BNT162b2 vaccine, mRNA-1273 vaccine, and AZD1222 vaccine. We extensively describe the different excipients in the vaccines with the potential to elicit systemic allergic reactions such as polyethylene glycol (PEG), polysorbates, tromethamine/trometamol, and others and the possible immunological mechanisms involved.     

Anaphylaxis: clinical aspects.

Anaphylaxis is a rarely anticipated, potentially life-threatening systemic allergic reaction with symptoms ranging from mild flushing to upper respiratory obstruction with or without vascular collapse. Early recognition of symptoms with prompt institution of therapy is central to a successful outcome. Anaphylaxis is IgE mediated, whereas non-IgE mediated anaphylatic reactions are termed anaphylactoid. Food-induced anaphylactic reactions, particularly peanut, are being recognized with increasing frequency. Central to appropriate therapy of the acute reaction is adminstration of intramuscular adrenalin. However, with the advent of humanized anti-IgE monoclonal antibody, such reactions may be reduced in frequency and severity.     

抗血吸虫DNA疫苗pcDNA3／SjHGPRT局部肌肉刺激与全身过敏实验

目的评价日本血吸虫DNA疫苗pcDNA3／SjHGPRT的安全性。方法同体左右侧自身对比法对3只家兔进行局部肌肉刺激实验,22只豚鼠随机分为4组：无菌生理盐水阴性对照组、牛血清白蛋白阳性对照组、pcDNA3／sjHGPRT低剂量组、pcDNA3／SjHGPRT高剂量组,进行全身过敏试验。结果日本血吸虫DNA疫苗pcDNA3／SjHGPRT对家兔局部肌肉刺激反应轻微,对豚鼠无全身过敏反应。结论日本血吸虫DNA疫苗pcDNA3／SjHGPRT在该实验条件下安全。     

Position document: IgE-mediated allergy to egg protein

Egg is the food that most often causes allergy in young Spanish children, with an incidence of 2.4–2.6% in the first 2 years of life. The prevalence of sensitisation and allergy to egg is greater in children with allergy to cow's milk and in those suffering atopic dermatitis. The protein component from egg white is the cause of the allergic response in child. The major allergens in egg white are ovomucoid and ovalbumin. Most of the allergic reactions affect the skin, followed by gastrointestinal and respiratory systems. Egg allergy is one of the most common causes of severe anaphylaxis. The diagnosis of egg allergy is based on the existence of a suggestive clinical history, a positive allergy study and the subsequent application of controlled exposure testing, which represents the gold standard for confirming the diagnosis.The treatment of egg allergy is based on the avoidance of egg protein intake. A subgroup of egg-allergic patients are tolerant to cooked egg. In these cases, only uncooked egg must necessarily be avoided. Maintaining a diet with strict egg avoidance is difficult, and transgressions are relatively common. The patient, family, and school environment should receive education and training in the avoidance of egg and in the management of possible allergic reactions. With an avoidance diet, up to 15–20% of children will remain allergic and the severity of the reactions will increase over the years. In these more severe cases of egg-allergy, it becomes more difficult to adhere to the avoidance diet over the years, with a significant decrease in patient quality of life.Oral tolerance induction can be regarded as a therapeutic option for IgE-mediated egg allergy. The anti-IgE, omalizumab, might become another genuine therapeutic option for food allergy, not only to prevent allergic reactions after a contact with egg, but also as a complementary treatment to oral tolerance induction for egg allergy, with the purpose of reducing adverse reactions.The administration of influenza vaccine to children with egg allergy is safe in children that do not manifest severe reactions after egg intake, and in children who tolerate cooked egg. The triple viral vaccine (MMR) can be given to egg-allergic children in their usual vaccination centre, with no added risk. Different medicinal products can be formulated with egg proteins, and therefore should be avoided in children with egg allergy.     

Pre-exposure prophylaxis in Peace Corps volunteers with intradermal human diploid cell rabies vaccine

The Peace Corps has had approximately 60 000 person/years of experience with rabies pre-exposure duck embryo vaccine (DEV) immunizations, which are required in 80% of volunteer assignments. Rabies exposure treatment rate is much higher in these areas than in the United States. One death from rabies has occurred despite pre-exposure injections. One death also occurred from serum hepatitis contracted in local emergency management of an anaphylactic reaction to duck embryo vaccine. A query to the Peace Corps field medical offices obtained reports of 21 serious reactions in approximately 8000 duck embryo immunizations. Two thirds of the reactions occurred with the first injection. Only a third of titres measured after four injections of DEV achieved a protective level of greater than or equal to 1:16. Because of these problems human diploid intracellular vaccine (HDCV) was studied in areas where it was available. Because of the high cost and initial short supply, intradermal injections of 0.1 ml HDCV were given. 567 of 570 persons achieved adequate titres. No systemic reactions were reported with intradermal HDCV.     

Réaction anaphylactoïde post-BCG : le rôle du dextran ?

The authors describe the case of a 16-year-old male without any medical history who developed anaphylactic shock a few minutes after the injection of the intradermal vaccine BCG Pasteur. Chronology of events, lack of any other drug intake and the dramatic increase of serum tryptase level account for the anaphylactic reaction consecutive to vaccine injection. A few weeks after the accident, the allergic data donˈt reveal much. At this time, serum anti dextran IgG are significantly high (8 mg/L), suggesting the involvement of dextran in this severe adverse reaction.     

Skin reaction to yellow fever vaccine after immunization with rabies vaccine of chick embryo cell culture origin

Skin reaction to yellow fever vaccine was examined after immunization with rabies vaccine. The two vaccines contained substrates from chick embryo cells (rabies vaccine) and chick whole embryo (yellow fever attenuated vaccine), as well as gelatin. A prick test with gelatin showed negative results in all vaccinees examined. An intradermal skin test revealed that the yellow fever vaccine had reacted with an anti-egg protein antibody-like substance in a case with a history of egg allergy before rabies vaccination. A case inoculated two times with the rabies vaccine revealed a positive reaction to egg-white protein as well as the yellow fever vaccine. This case had no anamnesis of egg allergy. Thus, an antibody reactive to the egg-white protein and/or the yellow fever vaccine was inducible by the rabies vaccine. The reaction of this antibody was not systemic but local at the skin test by the yellow fever vaccine. The period of the rabies vaccine sensitization reactive to the yellow fever vaccine could be estimated as longer than 14.3 +/- 9.6 days (mean +/- SD), based on a follow-up examination of the positive skin reaction in 41 of 84 cases examined. We therefore conclude that the yellow fever vaccine can be safely administered at an interval of at least four weeks after a second rabies vaccination.     

Hypersensitivity reactions to rifampin. Pathogenetic mechanisms, clinical manifestations, management strategies, and review of the anaphylactic-like reactions

Many of the adverse events induced by rifampin have been considered allergic in origin. The flu-like syndrome and other hypersensitivity reactions seem to be caused by immune complexes, although their pathogenetic mechanisms are not fully elucidated. Many cases have been reported of the flu-like syndrome, thrombocytopenia, hemolytic anemia, and renal failure caused by rifampin. In almost all of the patients in whom they were sought, nonreaginic antirifampin antibodies were detected. On the other hand, anaphylactic reactions seem to be IgE-mediated. We have analyzed the 18 reported cases of anaphylactic reactions severe enough to cause marked hypotension. The interval between the onset of treatment and the anaphylactic reaction was highly variable. Most patients presented with prodromes, mainly rash, before the development of anaphylactic symptoms, and, in most cases, the reaction occurred after reexposure to rifampin. Clinical findings include a variety of symptoms, such as fever, exanthem, dyspnea, abdominal pain, and vomiting. Seven of the 9 patients in whom HIV status was known were seropositive, including the only 2 patients who died. We believe that, in case of a non-life-threatening adverse reaction caused by immune complexes, rifampin could be readministered, if necessary, at a more frequent and reduced dose, perhaps with the addition of corticosteroids. In case of anaphylactic reactions the drug should be avoided, although desensitization procedures may be useful. Certain laboratory findings may serve as a clue to predict anaphylactic reactions in patients who have experienced minor adverse events to rifampin. However, the diagnostic value of such findings is not well established and, therefore, patients with previous adverse reactions should be carefully monitored if reexposure to rifampin is essential.     

Adverse reactions to neuromuscular blocking agents

Neuromuscular blocking agents (NMBAs) play a predominant role in the incidence of severe adverse reactions occurring during anesthesia. Most hypersensitivity reactions are of immunologic origin (IgE-mediated) or are related to direct stimulation of histamine release. The incidence of IgEmediated hypersensitivity or anaphylaxis is estimated between 1 in 10,000 and 1 in 20,000 anesthesias, and NMBAs represent the most frequently involved substances, with a range of 50% to 70%. Any suspected anaphylactic reaction must be extensively investigated using combined perioperative and postoperative testing. Because of the frequent cross-reactivity observed with muscle relaxants, every available NMBA should be tested. This should help provide documented advice for future administration of anesthesia. There is no demonstrated evidence for systematic preoperative screening in the general population at this time. Other well-known adverse effects have been described, such as the succinylcholine-triggered cytotoxic effects on muscle cells, but these are responsible for characteristic clinical symptoms, which are usually easy to distinguish from anaphylactic reactions     

Diphtheria boosters for adults: balancing risks

Combined tetanus-diphtheria vaccines are now the only means of protecting adults from tetanus or diphtheria. When advising on the benefits and risk of vaccinating for one disease, clinicians now have to consider the other vaccine component, and questions have arisen about where the balance of risk lies for different patients. Five doses of diphtheria-toxoid containing vaccine are probably sufficient protection for individuals who remain in low-incidence countries such as those in most of Western Europe. Adults who remain in the UK are extremely unlikely to be exposed to diphtheria and this needs to be taken into account when assessing the balance of risk where individuals have received fewer than five doses of diphtheria toxoid but five or more doses of tetanus toxoid. In contrast to diphtheria, if someone has received fewer than five doses of tetanus toxoid but is up to date for diphtheria toxoid, the balance of lifelong risk is probably in favour of giving tetanus toxoid irrespective of the individual's diphtheria status. For travellers to diphtheria endemic countries boosters are recommended if more than 10 years has elapsed since the last dose. For individuals who have already received five or more doses of tetanus vaccine in the past, receiving further boosters of tetanus in combination with diphtheria toxoid is unlikely to cause any significant reactions. The only absolute contraindication to such boosters is a previously documented anaphylactic reaction to either diphtheria or tetanus toxoid. Individuals who have a history of such a reaction should be well advised regarding probable risk of infection, symptoms of the disease and the need to seek early treatment.     

Anaphylactic transfusion reactions

PURPOSE OF REVIEW: Although anaphylactic reactions to blood products are rare, the incidence of allergic reactions to blood products is similar to the allergic reaction incidence to penicillin antibiotics, and therefore worthy of proportionate attention.Comprehensive reviews and guidelines of the management of anaphylaxis currently do not include much information on blood products. Current guidelines for the specific management of anaphylactic transfusion reactions are contradictory as to the utility of anti-IgA testing and incomplete by not offering suggestions for the management of non-IgA related reactions. RECENT FINDINGS: Anti-IgA is not responsible for most reactions. Anti-haptoglobin antibodies are responsible for more reactions than anti-IgA in Japan, but the cause of most reactions is still not known. The incidence of reactions to platelets is the highest compared with fresh frozen plasma and red blood cells. Pre-storage white blood cell reduction of platelets does not decrease the incidence of reactions, indicating that white blood cell-derived cytokines are not responsible for most reactions. SUMMARY: The increased incidence of reactions to platelets compared with fresh frozen plasma suggests that a platelet-related factor may be responsible for many of the reactions. The possible role of platelet microparticles or activated platelet membranes, which carry a negative charge similar to ionic radiocontrast media, the major cause of iatrogenic anaphylactic reactions in the hospital, is explored.     

Choc anaphylactique au cours d’une anesthésie : de la physiologie au traitement

The incidence of allergic reactions occurring during anesthesia in France is estimated to be from 1:3500 to 1:13 000 anesthesias. Anaphylaxis, the most serious form, can be expressed in a single organ, for example, as bronchospasm, or as isolated cardiac arrest. The most frequent mechanism of these reactions is immunologic, IgE-mediated or otherwise; other mechanisms are non-immunologic. Treatment of these reactions is an emergency, whatever the mechanism. It is well standardized and depends on the severity of the reaction. Symptomatic treatment should be started upon observing local cutaneous signs. When there is significant hypotension, rapid vascular loading and administration of epinephrine are necessary, even in the presence of tachycardia; the size of the epinephrine bolus must be adapted to the severity of the reaction. Bronchospasm must be treated with epinephrine when administration of a beta-2 agonist is ineffective. When there is cardiac arrest, the classical resuscitation measures for cardio-respiratory failure are required. Following a perioperative anaphylactic reaction, an allergy workup should be done to identify the drugs administered and the mechanism involved. The results of this workup must be taken into account during future operative procedures.     

Utility of desensitisation for allergy to antibiotics

Immediate-type allergic reactions to medication are potentially life threatening and can hamper the drug therapy of several medical conditions. If no alternative drug treatment is available, a desensitisation procedure may secure the continuation of necessary therapy by inducing a temporal state of tolerance. Desensitisation is only appropriate in case of a strong suspicion of an IgE-mediated allergic reaction. It should be performed by trained clinicians (allergy specialists) in a hospital setting where treatment of a potential anaphylactic reaction can be done without any delay. In this article, literature describing desensitisation procedures for several antibiotics is reviewed.     

Guideline on the investigation and management of acute transfusion reactions Prepared by the BCSH Blood Transfusion Task Force

Although acute non‐haemolytic febrile or allergic reactions (ATRs) are a common complication of transfusion and often result in little or no morbidity, prompt recognition and management are essential. The serious hazards of transfusion haemovigilance organisation (SHOT) receives 30–40 reports of anaphylactic reactions each year. Other serious complications of transfusion, such as acute haemolysis, bacterial contamination, transfusion‐related acute lung injury (TRALI) or transfusion‐associated circulatory overload (TACO) may present with similar clinical features to ATR. This guideline describes the approach to a patient developing adverse symptoms and signs related to transfusion, including initial recognition, establishing a likely cause, treatment, investigations, planning future transfusion and reporting within the hospital and to haemovigilance organisations. Key recommendations are that adrenaline should be used as first line treatment of anaphylaxis, and that transfusions should only be carried out where patients can be directly observed and where staff are trained in manging complications of transfusion, particularly anaphylaxis. Management of ATRs is not dependent on classification but should be guided by symptoms and signs. Patients who have experienced an anaphylactic reaction should be discussed with an allergist or immunologist, in keeping with UK resuscitation council guidelines.     

Réactions allergiques et pseudoallergiques aux médicaments et substances biologiques chez l’enfant

Five to 20% of subjects of all ages report suspected allergic reactions to drugs and biological substances. Children may be less affected than adults, but this difference is disputed and probably results from differences in drug exposure. Most frequently suspected drugs are antibiotics, betalactams especially, antipyretics, analgesics and nonsteroidal anti-inflammatory drugs. Most frequent reactions are morbilliform/maculopapular rashs, urticaria and angioedema. Other cutaneous and respiratory reactions, and severe anaphylactic and anaphylactoid reactions, are rare. The results of allergological studies suggest that, except for a few types of reactions (anaphylactic and immediate reactions, potentially harmful toxidermias) and for very specific drugs (i.e. latex and myorelaxants), most reactions to commonly used drugs and biological substances in children do not result from drug hypersensitivity, but are rather a consequence of the infectious and/or inflammatory diseases for which the drugs have been prescribed. The reactions may also result from complex interactions between drugs, immune system and “danger” signals provided or induced by infectious and/or inflammatory diseases. Diagnosis is based above all on a detailed analysis of clinical history, skin tests (if validated) and challenge tests (if indicated). In children with drug allergy or intolerance, prevention of relapse is based on a rigourous avoidance of the responsible drug and cross-reacting drugs.     

Intraoperative anaphylactic shock in a child with no history of type I hypersensitivity

Natural rubber latex is the second most implicated agent in intraoperative anaphylactic reactions. This report describes a case of intraoperative anaphylaxis occurring in a non-atopic fourteen-year-old girl undergoing multiple surgical procedures, but without spina bifida, in which latex surgical gloves were the main culprit for the anaphylactic reactions. Clinical manifestations of an anaphylactic reaction were also experienced during the examination of the possible cause of intraoperative anaphylaxis by skin prick testing with a latex allergen extract. Skin tests with anesthetics were negative. Specific IgE to latex was positive at 92.9 kUA/L (class 5). The molecular basis for the reported intraoperative anaphylaxis was ascribed to three low-molecular mass latex allergens (10-15 kD) detected in the brand of latex surgical gloves used during the operation. Given the potential of a dramatic outcome, latex allergy testing as a regular preoperative measure may contribute to the reduction of anaphylactic reactions during surgical interventions.     

Accidents graves par allergie alimentaire en France : fréquence,caractéristiques cliniques et étiologiques. Première enquête du Réseau dˈallergovigilance,avril–mai 2001

The first questionnaire of the ‘Allergy Vigilance Network’ concerns severe anaphylactic reactions that occurred during 1 month (April or May 2001). The first results obtained from 100 members of the Network (74 allergologists-GPs, 15 pediatricians-allergologists, eight lung specialists-allergologists and three dermatologists-allergologists) were collected. The analysis of these 100 answers reveals the occurrence of 163 severe reactions: laryngeal angioedema (51.5%), anaphylactic shock (39.9%), acute asthma (8.6%). These reactions concern 46.6% children under 15 years of age and 53.4% adults. The most frequent allergens are peanuts and nuts (27.6%), food cross-reacting with latex (11%), egg (8.6%), fish (6.7%), crustaceans (5.5%), milk (4.3%), sesame (4.3%), wheat (3.6%), legumes (3.6%), shellfish (3%), mustard (1.8%), celery (1.8%), and additives (carmine, alpha-amylase and sulfites: 1.8%). Severe reactions in France could be estimated between 15,000 and 30,000 per year. Acute asthma is less commonly reported, mainly by lung specialists, and is probably underestimated. The ability of nuts to induce severe allergic reactions is confirmed. This survey underlines the increased frequency of severe reactions to food cross-reacting with latex and to sesame. The frequency of food allergens could be influenced by the season; this enquiry will be renewed in January 2002.