- Immunization is perhaps the greatest public health achievement of all time, having significantly reduced the morbidity and mortality of many infectious diseases.
- There are approximately 235 million doses of vaccines administered in the United States each year.
- Anaphylactic reactions to vaccines are estimated to occur at a rate of approximately 1 per million doses.
- Patients with suspected allergy to vaccines or vaccine components should be evaluated by an allergist/immunologist.
- Most patients with suspected allergy to vaccines can receive vaccination safely.
Diagnosis and Assessment
- Mild local reactions and constitutional symptoms, such as fever, after vaccinations are common and do not contraindicate future doses. Rarely, delayed-type hypersensitivity to a vaccine constituent may cause an injection site nodule, but this is not a contraindication to subsequent vaccination. (C)
- All serious events occurring after vaccine administration should be reported to the Vaccine Adverse Event Reporting System (http://vaers.hhs.gov/), even if it is not certain that the vaccine was causal. (C)
- Measuring levels of IgG antibody to the immunizing agent in a vaccine suspected of causing a serious adverse reaction to determine if they are at protective levels can help determine whether or not subsequent doses are required. (B)
- All suspected anaphylactic reactions to vaccines should ideally be evaluated in an attempt to determine the culprit allergen. (B)
- IgE-mediated reactions to vaccines are more often caused by vaccine components, such as gelatin or egg protein, than the immunizing agent itself. (B)
- Patients who have had an apparent anaphylactic reaction after immunization should undergo immediate-type allergy skin testing to help confirm that the reaction was IgE-mediated and to determine the responsible component of the vaccine. (B)
- If the intradermal skin test result is negative, the chance that the patient has IgE antibody to any vaccine constituent is negligible, and the vaccine can be administered in the usual manner. It is prudent, nonetheless, in a patient with a history suggestive of an anaphylactic reaction to administer the vaccine under observation with epinephrine and other treatment available. (B)
- In patients with histories and skin tests results consistent with an IgE-mediated reaction to a vaccine, who require additional doses of the suspect vaccine or other vaccines with common ingredients, consideration can be given to administering the vaccine in graded doses under observation. (C)
- Some more serious, and less common, reactions to vaccines require evaluation, but only a few are absolute contraindications to future doses. (B)
- Pregnant women should not be vaccinated with live vaccines. However, pregnant women should be given inactivated influenza vaccine as well as tetanus and hepatitis B vaccine if otherwise indicated. (B)
- In general, live vaccines should not be given to persons who are immune- compromised because of a risk of generalized infection with the immunizing agent. (B)
- Specific vaccines or vaccination in general has been purported to have long-term consequences, including atopy, autism, and multiple sclerosis. Epidemiologic studies have not supported such associations. (B)
- Bacille Calmette-Guerin (BCG)
- Influenza (intranasal)
- Measles-mumps-rubella (MMR)
- Oral poliovirus (OPV)
- Typhoid (oral)
- Vaccinia (smallpox)
- Yellow fever
- Diphtheria, tetanus and acellular pertussis (DTaP, Tdap)
- Diphtheria-tetanus (DT, Td)
- Hepatitis A
- Hepatitis B
- Hib conjugates
- Human papillomavirus (HPV)
- Inactivated poliovirus (IPV)
- Influenza (injectable)
- Japanese encephalitis
- Meningococcal conjugate
- Pneumococcal conjugate
- Typhoid (injectable)
[Note 1] Probable Anaphylactic Reaction
- Reaction occurring within 4 hours of vaccine administration to include signs and/or symptoms from more than 1 of the following systems:
- Dermatologic: urticaria, flushing, angioedema, pruritus
- Respiratory: rhinoconjunctivitis (red, watery, itchy eyes; stuffy, runny, itchy nose, sneezing), upper airway edema (change in voice, difficulty swallowing, difficulty breathing), bronchospasm/asthma (cough, wheeze, shortness of breath, chest tightness)
- Cardiovascular: hypotension, tachycardia, palpitations, light-headedness, loss of consciousness
Comment: hypotension or loss of consciousness with pallor and bradycardia is much more likely a vasovagal reaction.
- GI: cramping, nausea, vomiting, diarrhea
- Possible Anaphylactic Reaction:
- Signs and/or symptoms from only 1 system (as above)
- Signs and/or symptoms from more than 1 system (as above) but occurring more than 4 hours after vaccination
[Note 2] Vaccine Skin Tests
- Prick test with full strength vaccine (consider dilution if history of life-threatening reaction)
- If prick test with full strength vaccine is negative, intradermal test with 0.02 cc vaccine 1:100
Comment: Vaccine skin tests may cause false (or clinically irrelevant) positive reactions.
- Vaccine component/food skin prick tests:
- Influenza: whole egg or egg white
- Yellow fever: whole egg or egg white, chicken & gelatin
- Hepatitis B vaccine and Human Papillomavirus: Saccharomyces cerevisiae yeast
- DTaP (some brands), influenza (some brands), Japanese encephalitis, measles, mumps, rabies (some brands), rubella, varicella, zoster: gelatin
Comment: sugared gelatin (eg, Jell-O®: dissolve 1 teaspoon (5 grams) of gelatin powder in5 cc normal saline)
- If fewer than the recommended number of doses received, consider measuring level of IgG antibodies to immunizing agent. If at a level associated with protection from disease, consider withholding additional doses although magnitude and duration of immunity may be less than if all doses received.
- Vaccine administration in graded doses:
- For a vaccine where usual dose is 0.5 mL, administer graded doses of vaccine at 15 minute intervals: 0.05 mL of 1:10 dilution, 0.05 mL of full strength, 0.10 mL of full strength, 0.15 mL of full strength, 0.20 mL of full strength.
- For influenza vaccine in egg-allergic patients, if the egg protein content of the vaccine is known to be ≤ 1.2 mcg/mL, administer 10% of the dose, followed in 30 minutes by the remaining 90%, or as a single dose.