Tag Archives: Influenza vaccine

Top 10 Allergy & Clinical Immunology Articles of 2011

From Medscape Allergy & Immunology  by Marrecca Fiore

Introduction

Ever wonder what other allergists are reading?  After sorting through the long list of articles published on Medscape during the past year, it seems our member audience of allergists and clinical immunologists was most interested in:

  • Food allergies
  • Influenza
  • Itching

The top 10 articles list is comprised of the most-read content of 2011. If you missed any of these articles, please take a look at them now.  Thanks Marrecca for your work on compiling the list. 

The List–I’ll comment when appropriate!

10. Office-Based Oral Food Challenge Safely Diagnoses Food Allergy
A letter published August 11th in the Journal of Allergy and Clinical Immunology said that food challenges can be safely done in a physician’s office as long as certain precautions are taken.

  • Precautions include having resuscitative equipment in office during the challenge. 
  • What foods do you challenge to?  I’d start out with egg, milk, wheat to name a few. 
  • Some exciting potential for “desensitization” and oral tolerance as well.

9. Pathophysiology of Itch and New Treatments
As highlighted in this paper, the pathophysiology of itch is diverse and involves a complex network of cutaneous and neuronal cells. The article explains current treatments as well as experimental and promising therapies.

  • Patients would rather have ANY symptom except itching. 
  • Be careful!  Itching can be a result of correctable causes….like elevated bilirubin. Don’t miss this one.

8. What the New Food Allergy Guidelines Offer to Clinicians

Dr. Matthew Fenton from NIAID and Dr. Hugh Sampson, past president of AAAAI, review the food allergy guidelines and discuss how these principles should guide clinical practice.

  • The most important guideline to follow–please avoid a food “panel” which misleads many patients to think they have a food allergy & you may just have an irrelevant positive test. 

7. The Itch That Rashes
A 2-year-old presents with a persistently itchy rash. What is the most appropriate management?

6. Common Variable Immunodeficiency at the End of a Prospering Decade: Towards Novel Gene Defects and Beyond
This review highlights the most important publications of the past year, with an emphasis on novel findings in genetics and the immunophenotype of CVID.

5. Molecular Diagnosis of Peanut and Legume Allergy
Peanut- and legume-induced allergic reactions can be fatal and can significantly impair the quality of life of patients and their families. This paper reviews and discusses recent studies on the molecular diagnosis of peanut and other legume allergy.

4. I’m Struggling to Live on $160,000 a Year: MD Lament
Most people who don’t have “MD” or “DO” after their name would assume that $160,000 is a good annual income. However, many physicians find it a challenge to live on that amount. Why can some manage easily while others are struggling to pay the bills?

3. Hymenoptera Venom Immunotherapy
Hymenoptera stings can induce allergic systemic and occasionally fatal reactions. What is the best treatment?

  • Bee sting shots are >90% effective & I’ve learned much about allergy shots for pollens based on research for bee stings. 

2. Influenza Vaccine: Guidelines for Those With Egg Allergy
Vaccine expert Paul A. Offit, MD, explains the new influenza guidelines for individuals with egg allergy.

  • The bottom line: Flu shot is probably safe even in patients with egg allergy.  This was taboo only 5 years ago….the more you know, the less you know!

1. New Test for Peanut Allergy a Step Forward
Measuring antibody levels of 2 peanut protein components in patients may be a better predictor of allergic reactions than current diagnostics.

Runners-Up

These articles did not make our Top 10, but they came close.

Can Inhaled Corticosteroids Prevent Asthma Exacerbations?
ICS therapy is the mainstay of asthma treatment, but can it also be used as a preventive measure?

Helping Families Manage Food Allergy in Schools
School can be a frightening place for food-allergic children and their parents. Are physicians providing the best information to help them?

Food-induced Anaphylaxis
Food allergy is an increasing problem in homes and schools. How do we determine who is at increased risk for anaphylaxis?

As always, if you have difficulty reading or obtaining any of these articles, let me know–I’ll be glad to help.

Egg Allergy and the Flu shot–Updated recommendations

 Trivalent influenza vaccine (TIV) FLU SHOT is safe to use in children with severe egg allergy, and can be given as a single dose, according to research presented at the American College of Allergy, Asthma & Immunology 2011 Annual Scientific Meeting.  I attended this session and the research presented definitely changes recommendations on giving the flu vaccine.
Eggs are delicious: but what about allergy?

This report confirms the recommendation made earlier this year by the Advisory Committee on Immunization Practices (ACIP) and the American Academy of Pediatrics (AAP) — that egg allergy is no longer a contraindication to vaccination with TIV.

Previously, the AAP Red Book considered anaphylaxis to egg or severe egg allergy a contraindication to receiving the vaccine.  When you grow vaccine in egg yolk this is understandable (see below). 

Growing influenza--beware of egg allergy...now you know why!

“The benefits of flu shots are well established and clearly outweigh the risks for children with egg allergy,” lead author Matthew J. Greenhawt, MD, from the University of Michigan in Ann Arbor, said in a statement. For the full interview, click on this link

“Children with food allergies are more likely to have asthma, which can increase their chance of respiratory complications from the flu. Expanding the population of children who receive flu shots will play an important role in decreasing influenza associated with hospitalization and in promoting the overall health of our children,” he explained.

Using a 2-step approach, the group randomized 28 children who were contraindicated for TIV according to previous AAP Red Book criteria to receive either a 10%/90% split dose of TIV (n = 13), or to receive normal saline plus 100% TIV (n = 15) to mimic the split dose.

In these 28 children, the mean egg skin test wheal was 7.7 mm, mean egg white ImmunoCAP was 23.1 kuA/L, mean ovalbumin ImmunoCAP was 20.4 kuA/L, and mean ovomucoid ImmunoCAP was 18.1 kuA/L.

There were no differences in these values between the 2 groups, Dr. Greenhawt reported.

In addition, they investigators retrospectively analyzed 32 children with severe egg allergy who were vaccinated by their primary care physician despite the contraindication, for comparison.

This retrospective group consisted of 13 children who received TIV as a split dose as a safety precaution and 19 who received it as a single dose. The mean egg white ImmunoCAP was 18.2 kuA/L, and there was no difference between children who received a single or a 2-step split dose of TIV.

None of the children developed an allergic reaction.

“Use of 2-step split dosing appears unnecessary, as a single dose was well tolerated by those who received this either in an allergy clinic or in the primary care setting,” Dr. Greenhawt concluded.

This change in clinical practice probably needs some reassurance!  Todd A. Mahr, MD, director of pediatric allergy/immunology at Gundersen Lutheran Medical Center in La Crosse, Wisconsin, and clinical professor of pediatrics at the University of Wisconsin Medical School in Madison, was comoderator of the session. He told Medscape Medical News that “the nice thing about this paper is that it reaffirms the ACIP and the AAP recommendations that have come out for administration of TIV in egg-allergic patients. This paper was actually submitted before [those recommendations] came out. It is nice to have it at our meeting to reconfirm the new recommendations.”

“What ACIP and AAP say now is that if the patient can eat egg cooked in things, the general practitioner can just go ahead and give TIV and watch the patient for 30 minutes afterwards,” said Dr. Mahr, who was not part of the current study.

Patients with a history of anaphylactic reaction to egg should be sent to a specialist for vaccination. “That specialist can decide what to do. One option is to do a 2-step dosing; another is to give it in 1 dose and be prepared to handle anaphylaxis,” Dr. Mahr said.

Dr. Greenhawt reports financial relationships with Phadia, Sunovion, and Nutricia. Dr. Mahr reports financial relationships with ISTA, Alcon, AstraZeneca, Genentech, GlaxoSmithKline, Merck, and Novartis.

American College of Allergy, Asthma & Immunology (ACAAI) 2011 Annual Scientific Meeting: Abstract 2. Presented November 6, 2011.

Egg allergy and influenza vaccine

Unfortunately, all influenza vaccines carry the admonition that egg allergic individuals may react to their administration. STOP….before reading any further, make sure you have a true egg allergy before you worry about the influenza vaccine.  Many patients have a positive TEST to eggs, but eat them just fine without any symptoms.  This isn’t an allergy and you have no need to worry about avoiding sunny side up  for breakfast. You do need to still get your flu shot!

There are no exceptions to this since all such vaccines are grown on media which may contain egg allergen. As always, there are clearly alternatives that are available to, in the vast majority of instances, allow the administration of influenza vaccine to egg allergic individuals.  In fact, new guidelines recommend giving the Flu vaccine even if you are allergic to egg….it’s tolerated very well and allergic reactions are quite rare (see below).

That makes me hungry

If you’re concerned, such patients can be tested to egg and influenza vaccine; testing & desensitization is usually highly successful in allowing the safe administration of influenza vaccine under these circumstances.

 Listed below are clinical studies demonstrating that patients with egg allergy can safely receive the influenza vaccine: J Allergy Clin ImmunolVolume 121, Issue 2, Supplement 1, Page S240 (February 2008).

Zeiger RS. Current issues with influenza vaccination in egg allergy. JACI 2002;110:830-40

J Allergy Clin Immunol Volume 123, Issue 2, Supplement, Page S175 (February 2009).

Soooo….how about some history of influenza vaccine? The original injectable influenza vaccine was developed at the University of Michigan in the mid-1940s. The vaccine was made by taking influenza virus, injecting it into embryonated hen’s eggs (see picture), and letting the virus grow in the chorioallantoic cells that surrounded the yolk sac. They harvest the egg, purify the virus, and kill the virus with formaldehyde. I’m sure this is more than anyone wants to know, but since the vaccine was made in eggs, a certain amount of contaminating egg protein, specifically, ovalbumin was always still present.

What do we do, then, about children and adults who are severely allergic to egg proteins? 

1.   During the last 15 years, we have gotten much better at protein purification, protein chemistry, and being able to purify the inactivated virus or the live attenuated virus without using ovalbumin. Thus, there is much, much less ovalbumin in current vaccines. (The quantity of egg protein in vaccine is expressed as the concentration of ovalbumin per dose or unit volume.  Check the package insert to find out if ovalbumin is < 1.4μg/mL; reaction rates are much less below this threshold)

2.  Children with egg allergy can receive the vaccine, but the Advisory Committee on Immunization Practices does recommend that, as a precaution for those who have more severe allergic manifestations like hives (or worse), those children should be given the vaccine in the presence of an allergist or someone who knows what to do should there be an anaphylactic reaction.  I think that’s a good idea.

3.  Ultimately, we will probably give the influenza vaccine much as we give the measles vaccine to children who are egg allergic now. Carefully, but most tolerate both vaccinations just fine.

Want more information–>check out the following resources:

 American Academy of Allergy

Prevention and Control of Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices (ACIP), 2011. MMWR Morbid Mortal Wkly Rep. [Early release: August 18, 2011.] Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm60e0818a1.htm?s_cid=mm60e0818a1_w Accessed August 22, 2011.