New Guideline: Flu Vaccine Safe for Persons With Egg Allergy

Janis C. Kelly

December 19, 2017

No special precautions are needed for flu shots in people allergic to eggs, according to an update to the influenza vaccine practice guideline from the Influenza Vaccine and Egg Allergy Practice Parameter Workgroup commissioned by Joint Task Force on Practice Parameters (JTFPP).

The revised guidance advises clinicians that the flu vaccine poses so little risk to egg-allergic patients that even asking about egg allergy is no longer necessary. Influenza vaccines can be administered to egg-allergic patients just as to those without egg allergy, without any special precautions.

Moreover, use of non–egg-based vaccines in egg-allergic individuals is "acceptable but not medically necessary or preferred." Live attenuated influenza vaccine (LAIV) may be administered to patients with egg allergy of any severity and of all ages but is not recommended for the 2017-2018 season "because of concerns regarding effectiveness."

The update is published in the January 2018 issue of Annals of Allergy, Asthma & Immunology.

"When someone gets a flu shot, health care providers often ask if they are allergic to eggs," said allergist Matthew Greenhawt, MD, chair of the American College of Allergy, Asthma, and Immunology (ACAAI) Food Allergy Committee and lead author of the practice parameter. "We want health care providers and people with egg allergy to know there is no need to ask this question anymore, and no need to take any special precautions. The overwhelming evidence since 2011 has shown that a flu shot poses no greater risk to those with egg allergy than those without."

This guidance applies to all US vaccine providers, including physician offices, healthcare system occupational/employee health sections, and retail pharmacy chains providing vaccine services.

The authors write, "Egg allergic patients can be vaccinated safely with influenza vaccines in the same manner as those without egg allergy. Previously recommended precautions, such as choice of a specific vaccine based on ovalbumin content (at least in countries where the known ovalbumin content in all available IIV [inactivated influenza vaccine] is <1 μg per dose), skin testing with the vaccine, and divided or graded dosing, are unnecessary. Similarly, specific waiting periods or special medical settings for the administration of influenza vaccine to egg allergic recipients are unnecessary."

The new ACAAI recommendations are consistent with those from the Centers for Disease Control and Prevention and from the American Academy of Pediatrics, all emphasizing the safety and importance of egg-allergic patients receiving their annual influenza vaccine. The JTFPP is a 12-member taskforce consisting of 6 representatives assigned by the American Academy of Allergy, Asthma, and Immunology and 6 by the ACAAI to oversee the development of practice parameters.

The change in guidance was based on a substantial body of data showing that the influenza vaccine does not contain enough egg protein to cause an allergic reaction, even in patients with severe egg allergy, according to the authors. Prior practice parameters had recommended that egg-allergic patients receive their vaccination at an allergist's office.

Allergist John Kelso, MD, ACAAI member and coauthor of the practice parameter, said in a press statement, "There are hundreds of thousands of hospitalizations, and tens of thousands of deaths in the United States every year because of the flu, most of which could be prevented with a flu shot. Egg allergy primarily affects young children, who are also particularly vulnerable to the flu. It's very important that we encourage everyone, including children with egg allergy, to get a flu shot."

As with other vaccines, anaphylaxis (which happens at the rate of about 1 case per million vaccinations) remains a concern, and the authors recommend that all vaccination providers have procedures in place for anaphylaxis management.

The authors add, "Furthermore, as with any vaccine, patients who have had an anaphylactic reaction to influenza vaccination itself, as opposed to a reaction to egg ingestion, should be evaluated by an allergist before subsequent vaccinations."

Participants in the JTFPP disclosed funding from various pharmaceutical companies and food-industry groups. According to the report, "At the workgroup level, members who have a potential conflict of interest either do not participate in discussions concerning topics related to the potential conflict or, if they do write a section on that topic, the workgroup completely rewrites it without their involvement to remove potential bias. In addition, the entire document is reviewed by the JTFPP and any apparent bias is removed at that level."

Ann Allergy Asthma Immunol. 2018;120:49-52. Full text

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