Page 5: Canadian Immunization Guide: Part 2 – Vaccine Safety
Anaphylactic Hypersensitivity to Egg and Egg-Related Antigens
Last partial content update (see Table of Updates): September 2016
Last complete chapter revision: June 2013
Egg allergy is one of the most common food allergies of childhood, with a prevalence of 1% to 3% in children under 3 years of age. It is often associated with eczema in infants and asthma in young children. As most children outgrow their egg allergy, the prevalence in adulthood is much lower and is estimated at 0.1%. The most common egg allergy is to egg white. Cross-sensitivity with egg yolk and chicken protein has been described.
Vaccines that contain small quantities of egg protein can cause hypersensitivity reactions in some people with allergies to eggs. In Canada, there are several vaccines manufactured by processes involving hens' eggs or their derivatives, such as chick cell cultures. This manufacturing process may result in the following vaccines containing trace amounts of residual egg and chicken protein:
- measles-mumps-rubella (MMR) vaccines
- measles-mumps-rubella-varicella (MMRV) vaccine
- influenza vaccines
- tick-borne encephalitis (TBE) vaccine
- RabAvert® rabies vaccine
- yellow fever (YF) vaccine
Hypersensitivity reactions occurring following receipt of these vaccines varies considerably in relation to the amount of residual egg and chicken protein in the vaccine.
Anaphylaxis after vaccination is rare. It may occur in people with anaphylactic hypersensitivity to eggs and in those with no history of egg allergy, due to other components in the vaccine. Due to this lack of predictability, immunization should always be performed by personnel with the capability and facilities to manage anaphylaxis post-vaccination. Refer to Early Vaccine Reactions Including Anaphylaxis in Part 2 for additional information regarding management of anaphylaxis in non-hospital settings.
Individuals should be asked about allergies to egg or chicken prior to vaccination with influenza, TBE, YF, or RabAvert® rabies vaccines. Prior egg ingestion is not a prerequisite for immunization with egg protein-containing vaccine. It should be noted that any vaccine is contraindicated in people who have had an anaphylactic reaction to a previous dose of the vaccine. Referral to an allergy specialist is recommended.
Atopic diseases are not a contraindication to immunization with egg protein-containing vaccine.
Measles and mumps-containing vaccine
Anaphylaxis after vaccination with MMR vaccine is rare. Studies of egg-allergic subjects have shown that there is no increased risk of severe allergic reactions to MMR vaccine. For example, a 1994 study reported no anaphylactic reactions in 500 children with a history of egg allergy immunized with MMR vaccine. Numerous other studies had the same outcome. A literature review conducted in 2000 concluded that administration of MMR vaccine is safe in children with egg allergy and egg allergy should not delay measles vaccination.
The trace amount of egg protein in MMR and MMRV vaccines appears to be insufficient to cause an allergic reaction in egg-allergic individuals. Skin testing is not recommended prior to vaccination as it does not predict reaction to the vaccine. MMR or MMRV vaccine can be administered in the routine manner to people who have a history of anaphylactic hypersensitivity to hens' eggs. Hypersensitivity reactions that do occur following MMR and MMRV vaccine are usually due to other components of the vaccine, such as gelatin or neomycin.
Anaphylaxis after vaccination with influenza vaccine is a rare consequence of hypersensitivity to a vaccine component. All influenza vaccines in Canada are currently manufactured by a process involving hens' eggs which may result in the vaccine containing trace amounts of residual egg protein. Although the ovalbumin (egg protein) content in influenza vaccines manufactured in eggs may vary from year to year, vaccines marketed in Canada are approved under a specification for ovalbumin content that is associated with low risks of adverse events.
Studies have demonstrated that egg-allergic persons can safely receive influenza vaccine. People with egg allergy, especially those with chronic conditions such as asthma, benefit from receiving influenza vaccine.
Egg-allergic individuals may be vaccinated against influenza using any of the vaccines authorized for use in Canada, without prior influenza vaccine skin test and with the full dose, irrespective of a past severe reaction to egg. The vaccine may be given in any settings where vaccines are routinely administered. However, as with all vaccine administration, immunizers should have the necessary equipment to be prepared to respond to a vaccine emergency at all times.
Referral to a specialist with expertise in allergies may be necessary in occasional circumstances where there is strong concern about proceeding with the recommendation above and the individual is at risk of complications from influenza. If the individual is not in a high-risk group, the need for vaccination may be reassessed.
Second dose in young children
Egg-allergic children who require a second dose of influenza vaccine during the same influenza season can, if the first dose is tolerated well, be given a second dose of the same product used for the initial administration, which need not be from the same vaccine lot.
The vaccine provider should discuss the risks of reactions, as should be done for any immunization, including the potential risk for an anaphylactic reaction after the observation period.
RabAvert® rabies vaccine is grown in chick embryo cell culture. Imovax® rabies vaccineis manufactured using human diploid cell cultures and therefore egg protein contamination is not an issue. For pre-exposure vaccination, Imovax ® rabies vaccine should be given to persons with a history of hypersensitivity reactions to egg or egg products as a precautionary measure. For post-exposure prophylaxis, the use of Imovax® vaccine is preferred for persons with a history of hypersensitivity to egg. If Imovax® vaccine is not available, RabAvert® vaccine should be administered with strict medical monitoring and facilities for emergency treatment of anaphylactic reactions readily available.
Tick-Borne Encephalitis Vaccine
Individuals with prior anaphylactic reactions to eggs or egg products should be vaccinated with TBE vaccine only under close clinical monitoring with readiness for emergency treatment.
Yellow fever vaccine
Yellow fever (YF) vaccine is prepared from virus grown in chick embryos and is the vaccine most likely to contain sufficient amounts of egg or chicken proteins to cause an allergic reaction in egg-allergic or chicken-allergic individuals. There have been several reports of anaphylactic reactions to YF vaccine in egg-allergic or chicken-allergic individuals; therefore, YF vaccine should not be routinely administered to egg-allergic or chicken-allergic individuals.
A 2010 case report documented a protocol for administration of YF vaccine in escalating doses to an egg-allergic individual with positive skin tests to YF vaccine. In a 2009 study of 7 egg-allergic subjects with strong local urticarial reaction to a 0.1 mL intradermal test dose of YF vaccine, the test dose was found to be sufficient to induce a protective antibody response. Referral of egg-allergic or chicken-allergic individuals to an allergy specialist is recommended as YF vaccination may be possible after careful evaluation, skin testing and graded challenge or desensitization.
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