Thursday, March 3, 2011

Egg Allergy and the Influenza Vaccine -- A New Perspective

From Medscape Allergy & Clinical Immunology
An expert interview with Matthew J. Greenhawt, MD, MBA

Laurie Scudder, DNP, NP

Editor's Note

The American Academy of Asthma, Allergy, & Immunology (AAAAI) issued a paper titled Administering Influenza Vaccine to Egg Allergic Recipients in October 2010.
The report offered guidance in the administration of influenza vaccine to egg-allergic (EA) individuals, concluding that most of these patients can safely be vaccinated. A follow-up practice parameter published in January 2011 provided more information about the quality of the evidence underpinning recommendations for vaccine administration.
Matthew J. Greenhawt, MD, MBA, Assistant Professor, University of Michigan Medical School, Division of Allergy and Clinical Immunology, and co-author of both reports discussed issues around implementation of these recommendations for both the primary care and allergy/immunology settings with Medscape editor Laurie Scudder DNP, NP.

The Evidence for Administration of Vaccine

Medscape: The report describes 3 recent studies that have examined the use of trivalent inactivated influenza vaccine (TIV) in egg-allergic individuals. Can you describe these studies?

Matthew J. Greenhawt, MD, MBA: During the 2009-2010 influenza season and H1N1 pandemic, 3 studies emerged examining this issue. The first was a retrospective study conducted by researchers at Boston Children's Hospital that examined their institution's experience in vaccinating their population of children with non-anaphylactic egg allergy.

A total of 171 patients met eligibility criteria and were vaccinated with trivalent influenza vaccine using a 2-step protocol without skin testing prior to vaccination. The 2-step protocol involved administering approximately 10% of the volume of the vaccine, then monitoring the child for 30 minutes to make sure that no symptoms developed, and then administering the residual 90% of the vaccine.
This is a common dosing protocol many allergists use to safely provide the vaccine to egg-allergic children.
In this study, there were 29 localized reactions, mostly redness or induration at the injection site.
There were 7 reactions considered to be systemic, 6 of which occurred within the initial 30-minute observation period after the 10% dose and one that occurred outside of that 30-minute observation period for the 90% dose.

The researchers' overall conclusion was that for egg-allergic children without a history of anaphylaxis, use of a 2-step graded dose approach is a valid and safe method of providing vaccination, and this can be done without any pretesting to the influenza vaccine.
This study did not report the ovalbumin content of the vaccines used. Ovalbumin is the egg protein that is a contaminant in influenza vaccine.
Additionally, it was a retrospective study and had fairly restrictive selection criteria, both factors that introduce some bias.
The design excluded kids who had a prior positive influenza vaccine skin test and/or a history of severe symptoms attributable to eggs.
So, although the patient population in this study was not entirely representative of the general egg-allergic population, this study importantly introduced the concept that vaccination can be safely performed without skin testing using a 2-step protocol.

The second study was a prospective multicenter trial conducted in Canada during the 2009-2010 pandemic.
This study used H1N1 influenza A vaccine that had been specifically formulated to contain approximately 0.3 μg/mL ovalbumin. This was a special vaccine not available in the United States. Patients were not skin tested to the vaccine prior to administration.
Two dosing strategies were used: 72 patients with a history of severe cardiovascular/respiratory symptoms attributable to egg or with uncontrolled asthma were vaccinated with a 2-step graded challenge; the remaining 758 egg-allergic individuals without such a history were vaccinated with a single dose.
A very low rate of reactions was found, with approximately 3% experiencing mild symptoms within a 1-hour observation period.
At 24 hours after vaccination, 13% had reported some mild symptoms, mainly gastrointestinal or runny nose.
Thus, the vaccine was well tolerated in this egg-allergic population.

Based on those results, a separate group of 3640 patients with self-reported egg allergy were vaccinated according to the same protocol. Among this additional group, symptoms consistent with an allergic reaction developed in approximately 2% of patients, with 2 patients requiring epinephrine. This study offered proof that a single-dose approach is acceptable and prospectively demonstrated that vaccine skin testing was not necessary to safely administer the vaccine. A
lthough this study was prospective and involved multiple centers, it did use a very specific vaccine type that was not available in the United States, which may hinder the ability to generalize these findings.
However, and most importantly, this study showed that egg-allergic patients without a history of a severe reaction could receive a low-ovalbumin containing vaccine safely without vaccine skin testing, and as a single dose.

The third study was done by our group at Michigan using H1N1 vaccine.
We conducted a controlled prospective study of 105 egg-allergic children and 19 non-egg-allergic controls. All patients, including controls, received skin testing. All control patients received a single-dose injection.
In the egg-allergic group, only those with negative vaccine skin testing received a single dose.
If the skin testing was positive, these patients were given a 2-step graded challenge.

The specific questions we were interested in were as follows:

* Is skin testing predictive of vaccine tolerance?
* Is a 2-step graded challenge rather than a single dose necessary?
* Does a patient's past egg allergy severity affect vaccine tolerance (given that influenza vaccine is technically contraindicated in children with anaphylaxis or with a severe reaction to egg)?
* Is vaccine ovalbumin content a factor in vaccine tolerance?

We found that 44 of our total group of both egg-allergic and non-egg-allergic patients had positive vaccine skin tests, but all received the vaccine without an allergic reaction developing.
Therefore, we concluded that the skin testing was not predictive of vaccine tolerance.
Interestingly, we found that as the vaccine ovalbumin content increased, all patients were more likely to have a positive skin test to the vaccine, which suggested that the vaccine may act as a skin irritant during testing.

We enrolled 25 egg-allergic patients with a history of anaphylaxis attributable to egg. Thirteen had a positive skin test and were vaccinated using a 2-step graded challenge. The remaining 12 had a negative skin test and received a single dose. All 25 received the vaccine safely without any symptom development.

Additionally, past recommendations suggested that booster doses of vaccine should be given using the same manufacturer lot because of concerns that different lots may contain different levels of ovalbumin.
In our study, 94 patients received a booster from a different lot, and none of the patients had any symptoms of allergic reaction, demonstrating that concerns about lot-to-lot variability may not be valid.

A limitation of our study was that the highest ovalbumin level in any of the vaccine lots used was 50 ng/mL. However, in a published study of vaccine ovalbumin levels, all 2009-2010 H1N1 ovalbumin levels analyzed were found to contain under 100 ng/mL, which was several-fold less than the trivalent influenza vaccine lots.

The findings from these studies, each using a different approach and methodology, all point to the same conclusions: that the vaccine is well tolerated in most egg-allergic patients, that vaccine skin testing is not necessary, and that there is evidence to support the use of either a single dose or a 2-step approach to safely administer the vaccine.

Medscape: The report also notes that a larger multicenter trial examining administration strategies for EA patients is currently underway. Are you able to tell us any more about that trial and the questions you hope it will answer?

Dr. Greenhawt: There is a study currently underway exploring the safety of this season's combined trivalent influenza vaccine (which contains H1N1) among a population of patients with severe egg allergy and/or anaphylaxis to egg, to evaluate the safety of providing the vaccine to this population.

159 comments:

Anonymous said...

buy tramadol in florida cheap tramadol without rx - tramadol 50 mg 4 times a day

Anonymous said...

buy ativan online ativan side effects frequency - ativan side effects/ringing in the ears

Anonymous said...

buy tramadol next day tramadol overnight fedex no prescription - tramadol 50 mg tab amneal

Anonymous said...

ativan online lorazepam online kopen - lorazepam 1mg espanol

Anonymous said...

can you buy tramadol online tramadol online no prescription overnight delivery - tramadol hcl 50 mg uses

Anonymous said...

buy tramadol medication buy tramadol eu - tramadol 50 mg et zoloft

Anonymous said...

buy tramadol buy tramadol online cash delivery - tramadol 50 mg high

Anonymous said...

buy tramadol without rx order tramadol overnight mastercard - tramadol vs vicodin

Anonymous said...

klonopin drug klonopin 1.5 mg erowid - klonopin vs xanax withdrawal

Anonymous said...

buy ativan online withdrawal 2mg ativan - ativan overdose signs and symptoms

Anonymous said...

buy tramadol online legal buy ultram online - buy tramadol spain

Anonymous said...

where to buy tramadol online tramadol dosage 10 lb dog - soma tramadol high

Anonymous said...

cheap clonazepam klonopin withdrawal with valium - klonopin side effects abuse

Anonymous said...

buy tramadol tramadol dosage slow release - order tramadol online with mastercard

Anonymous said...

best buy tramadol tramadol online 99 - where to order tramadol online

Anonymous said...

tramadol 100 mg tramadol withdrawal duration symptoms - buy tramadol online cod only

Anonymous said...

buy ambien online overnight ambien drug maker - ambien side effects death

Anonymous said...

generic ambien discount card for ambien - ambien side effects bloating

Anonymous said...

klonopin no prescription klonopin 2mg images - 2mg klonopin vs. 1mg xanax

Anonymous said...

buy tramadol online without a prescription tramadol no prescription cod - tramadol hcl 200 mg er

Anonymous said...

buy ativan online lorazepam 1 mg and xanax - took 8 mg of ativan

Anonymous said...

cheap soma soma yoga 02840 - order soma no prescription

Anonymous said...

tramadol cheap buy tramadol online tennessee - tramadol 50 mg narcotic

Anonymous said...

tramadol online tramadol 50mg with zoloft - tramadol dosage canine weight

Anonymous said...

zolpidem drug ambien generic drug cost - much does 10 mg ambien sell

Anonymous said...

soma without prescription soma frames - soma show on drug test

Anonymous said...

ativan medication uses for drug ativan - ativan jokes

Anonymous said...

buy tramadol online legal buy tramadol online united states - tramadol jerking

Anonymous said...

buy tramadol for dogs tramadol for dogs taken by people - order tramadol cod nc

Anonymous said...

ambien medication ambien cr and pregnancy - ambien generic vs brand

Anonymous said...

buy generic tramadol tramadol hcl headache - tramadol online overnight

Anonymous said...

cheap generic soma buy soma online usa - soma medication classification

Anonymous said...

tramadol online overnight buy 200 mg tramadol online - tramadol hcl usp

Anonymous said...

soma online illegal buy soma online - soma 4gs

Anonymous said...

cheap tramadol online tramadol xl - tramadol ultram over counter

Anonymous said...

klonopin pharmacy buy klonopin forum - klonopin wafers children

Anonymous said...

ambien online pharmacy ambien 10 mg dosage - ambien no prescription

Anonymous said...

buy tramadol with cod buy tramadol legally - buy cheap tramadol

Anonymous said...

buy ambien online safe to buy ambien online - buy ambien fast

Anonymous said...

buy viagra online viagra online canada - viagra online pharmacy india

Anonymous said...

can you buy viagra online legally generic viagra quick delivery - viagra online fast delivery

Anonymous said...

buy generic ambien ambien cr no prescription - ambien side effects crazy

Anonymous said...

buy tramadol overnight shipping buy tramadol online overnight uk - tramadol hcl 30

Anonymous said...

viagra buy viagra rxlist - buy viagra bangalore

Anonymous said...

cheap ambien no prescription ambience mall gurgaon review - generic ambien cost without insurance

Anonymous said...

ambien cost ambien withdrawal symptoms nightmares - ambience mall gurgaon entertainment

Anonymous said...

clonazepam drug many 2mg klonopin get high - klonopin urine

Anonymous said...

ambien 10mg ambien cr recreational use - ambien overdose canine

Anonymous said...

zolpidem 10 mg buy ambien cr online - how to order ambien from canada

Anonymous said...

buy ambien online legally ambien makes you sleep - 20 mg generic ambien

Anonymous said...

buy cheap soma generic soma 350 mg - buy soma online in texas

Anonymous said...

buy tramadol 100mg online purchase tramadol online cod - tramadol online yahoo

Anonymous said...

buy ambien no prescription ambien cr keeps me awake - ambien weight gain

Anonymous said...

buy sildenafil viagra for women gel - order viagra online ireland

Anonymous said...

carisoprodol without prescription soma usa online pharmacy - soma for sale cheap

Anonymous said...

generic soma online order soma online overnight delivery - buy generic soma online

Anonymous said...

buy viagra online pharmacy viagra buy online usa - viagra falls

Anonymous said...

viagra online purchase does viagra work in young men - buy viagra online get prescription

Anonymous said...

viagra for sale buy viagra pay with paypal - cheap viagra eu

Anonymous said...

buy tramadol 100mg buy tramadol overnight delivery no prescription - tramadol xr dosage

Anonymous said...

cheap soma what is soma medication used for - soma psychology

Anonymous said...

buy tramadol online tramadol for dogs after neutering - tramadol for dogs 10 mg

Anonymous said...

how to order viagra online safely generic viagra wikipedia - viagra 2 chainz hulk

Anonymous said...

viagra for sale off label viagra for women - best way to buy viagra in uk

Anonymous said...

buy viagra online buy viagra online next day - purchase viagra new zealand

Anonymous said...

cheap tramadol tramadol 50 mg weight loss - tramadol 50 mg for menstrual cramps

Anonymous said...

tramadol without prescription tramadol withdrawal hot flashes - tramadol sr tabs 100mg

Anonymous said...

cialis online cialis daily hypertension - cialis 5mg online canada

Anonymous said...

tramadol online where to buy tramadol online legal - ordertramadolonline.org

Anonymous said...

buy tramadol online buy tramadol line usa - buy tramadol 50mg online

Anonymous said...

buy viagra super active buy viagra online nz - viagra reviews

Anonymous said...

cialis online cialis daily not working - cialis price daily use

Anonymous said...

buy tramadol online can you buy tramadol over the counter in the us - buy tramadol online usa

Anonymous said...

discount propecia propecia cost at target - propecia lawsuit money

Anonymous said...

buy viagra online reviews purchase viagra spain - viagra dosage per day

Anonymous said...

buy viagra las vegas viagra rite aid - purchase viagra pills

Anonymous said...

propecia online propecia 0.5 - propecia without prescriptions uk

Anonymous said...

finasteride hair loss propecia 3 month shed - is generic propecia dangerous

Anonymous said...

cialis online where to buy cialis online in canada - get prescription cialis online

Anonymous said...

buy viagra online where can you buy viagra in stores - viagra online rip offs

Anonymous said...

tramadol online no prescription tramadol ld50 - ultram vs tramadol generic

Anonymous said...

buy tramadol online reviews buy tramadol florida - tramadol online bluebook

Anonymous said...

propecia cost buy generic propecia online cheap - generic propecia 5mg

Anonymous said...

generic tramadol online tramadol 50 mg mfg zydus - buy tramadol online usa

Anonymous said...

tramadol cheap 10 50 mg tramadol - can take 2 tramadol 50mg

Anonymous said...

buy tramadol online buy tramadol online missouri - tramadol much get high

Anonymous said...

buy viagra online without rx viagra online xlpharmacy - generic viagra super force

Anonymous said...

order tramadol online without prescription buy tramadol legally online - tramadol withdrawal chills

Anonymous said...

buy tramadol online no prescription cod tramadol withdrawal for dogs - tramadol hcl 50 mg strength

Anonymous said...

viagra pharmacy buy viagra online with paypal - buy viagra in germany

Anonymous said...

buy retin-a retin-a reviews acne - retin-a micro 0.1 gel coupon

Anonymous said...

buy retin-a without prescription buy retin a 1.0 - buy retin usa

Anonymous said...

buy tramadol online troy hill pharmacy online tramadol - cheap tramadol next day

Anonymous said...

tramadol online tramadol 50 mg cheap - tramadol hcl 50 mg overdose

Anonymous said...

buy tramadol online tramadol hcl high effects - buy tramadol online

Anonymous said...

buy propecia propecia hair loss - cost for generic propecia

Anonymous said...

retin a online pharmacy retin a tretinoin for wrinkles - buy retin a usa

Anonymous said...

buy retin-a buy retin a cream usa - where to buy retin a cream

Anonymous said...

purchase tramadol tramadol hcl 50 mg 319 - buy-tramadol

Anonymous said...

buy tramadol rx tramadol to get high - tramadol 2012

Anonymous said...

buy tramadol buy tramadol cod shipping - buy tramadol injection

Anonymous said...

buy tramadol overnight tramadol for dogs empty stomach - buy-tramadol

Anonymous said...

cheap tramadol purchase tramadol overnight - can you buy tramadol in greece

Anonymous said...

cheap tramadol tramadol generic - buy tramadol texas

Anonymous said...

buy retin-a online retin-a micro gel and breastfeeding - buy retin-a eu

Anonymous said...

buy tramadol cod can you buy tramadol otc - tramadol dose

Anonymous said...

tramadol no prescription tramadol long term effects - tramadol for dogs buy

Anonymous said...

buy propecia online where to buy propecia in india - will there generic propecia

Anonymous said...

tramadol online cod tramadol hcl dogs dosage - tramadol for dogs for sale

Anonymous said...

buy cheap tramadol tramadol ultram same thing - tramadol addiction 2010

Anonymous said...

tramadol overnight shipping tramadol dosage in humans - get off tramadol addiction

Anonymous said...

cheap viagra buy viagra online fast shipping - can i buy viagra online legally

Anonymous said...

tramadol 50 mg buy tramadol overnight with mastercard - tramadol overdose help

Anonymous said...

cheap cialis online online apotheke cialis 20mg - cialis online western union

Anonymous said...

buy tramadol buy tramadol from canada - tramadol hcl strength

Anonymous said...

buy viagra no prescription buy viagra kuala lumpur - buy viagra using paypal

Anonymous said...

tadalafil 20mg generic cialis pictures - cialis daily for bph

Anonymous said...

buy soma online soma medication information - buy soma online mastercard

Anonymous said...

cheap soma online buy soma online with mastercard - cheap soma pills

Anonymous said...

soma online buy soma online cheap - legal order soma online

Anonymous said...

soma online soma online next day - pills similar to soma

Anonymous said...

buy soma online soma san diego concerts - buy somatropin malaysia

Anonymous said...

buy retin a buy prescription retin a cream - retin a cream retinol

Anonymous said...

buy soma soma pills erowid - soma scheduled drug nevada

Anonymous said...

buy soma online buy soma online pharmacy - where to buy aura soma bottles

Anonymous said...

soma online soma generic fedex no prescription - soma drug test information

Anonymous said...

soma cheap soma medication for pain - soma drug coupon

Anonymous said...

cheap soma online soma the pill - order generic soma

Anonymous said...

soma online pharmacy order soma ship texas - generic form of soma

Anonymous said...

buy retin buy retin a cream usa - buy retin a cream 0.05

Anonymous said...

can you buy tramadol online legally can buy tramadol online uk - tramadol 37.5 high

Anonymous said...

buy tramadol order tramadol online from usa - buy tramadol online reviews

Anonymous said...

buy tramadol hcl high off tramadol 50 mg - what is a normal dosage of tramadol for dogs

Anonymous said...

buy retin a retin a micro gel no prescription - retin-a pregnancy

Anonymous said...

buy tramadol online mastercard overnight 300 mg tramadol high - buy tramadol online cheap

Anonymous said...

buy tramadol free shipping tramadol high stories - tramadol for purchase no prescription

Anonymous said...

buy tramadol 180 buy prescription ultram - buy tramadol hydrochloride online uk

Anonymous said...

buy tramadol venta tramadol online - can i order tramadol online legally

Anonymous said...

buy cialis online cheap cialis eu - buy cialis online legal

Anonymous said...

cialis online no prescription buy cialis brisbane - cost daily cialis nz

Anonymous said...

tramadol 50mg tramadol dosage and side effects - order tramadol online cod overnight

Anonymous said...

buy tramadol online good place buy tramadol online - tramadol 100 mg street value

Anonymous said...

cheap tramadol best place buy tramadol online - buy tramadol no prescription canada

Anonymous said...

cheap tramadol tramadol cod - tramadol 50 mg buy online

Anonymous said...

legal buy tramadol online buy tramadol in europe - tramadol to buy online in usa

Anonymous said...

xanax online xanax withdrawal heart rate - xanax street value 1mg

Anonymous said...

tramadol online buy tramadol online co.usa - tramadol for migraines

Anonymous said...

buy generic xanax pink xanax pills mg - xanax dosage pictures xanax

Anonymous said...

xanax online xanax dosage not working - xanax withdrawal after 2 weeks

Anonymous said...

tramadol online tramadol tolerance - tramadol 50 mg a narcotic

Anonymous said...

tramadol online buy tramadol online with credit card - buy tramadol online pharmacy

Anonymous said...

buy cialis online generic cialis online us - cialis jelly sachet

Anonymous said...

buy cialis online usa cialis 4 mg - cheap cialis no prescription

Anonymous said...

buy klonopin online generic klonopin 2mg - klonopin r33

Anonymous said...

buy tramadol overnight tramadol for dogs safe - tramadol 50 mg tablets

Anonymous said...

buy tramadol rx tramadol for dogs safe - tramadol hcl headache

Anonymous said...

http://www.integrativeonc.org/adminsio/buyklonopinonline/#cheap klonopin 5 htp - klonopin generalized anxiety disorder gad ratings

Anonymous said...

Its like you read my mind! You seem to know so much about this, like you
wrote the book in it or something. I think that you could do with some pics to drive the message
home a bit, but instead of that, this is fantastic blog.
An excellent read. I'll certainly be back.

Also visit my homepage; maescentics.medellin.unal.edu.co

Anonymous said...

buy tramadol online cheap order tramadol overnight - tramadol generic