When is the COVID (Coronavirus Disease 2019) vaccine contraindicated?

COVID-19 Vaccine Contraindications

The COVID-19 vaccine is contraindicated only in individuals with a documented severe allergic reaction (anaphylaxis) to a previous dose of the COVID-19 vaccine or to any component of the vaccine, particularly polyethylene glycol (PEG) or polysorbate. 1

Absolute Contraindications

1. Severe allergic reaction to previous dose

   • Anaphylaxis or severe allergic reaction after receiving a previous dose of COVID-19 vaccine 1
   • Requires evaluation by an allergist to determine if future vaccination is appropriate 1

2. Known allergy to vaccine components

   • Polyethylene glycol (PEG) - present in Pfizer/BioNTech and Moderna mRNA vaccines 1
   • Polysorbate 80 - present in Oxford/AstraZeneca and Johnson & Johnson adenoviral vector vaccines 1
   • Confirmed by positive skin test for these components 1

Temporary Contraindications (Delay Vaccination)

1. Acute moderate to severe COVID-19 infection

   • Vaccination should be deferred until recovery from acute illness 1
   • Patients with mild COVID-19 illness may be vaccinated 1

2. Current severe febrile illness

   • Defer vaccination until resolution of acute symptoms 1
   • Minor illnesses with or without fever are not contraindications 1

Special Considerations (Not Contraindications)

1. History of allergies not related to vaccines

   • Food allergies
   • Environmental allergies
   • Allergies to medications not containing PEG or polysorbate
   • Egg allergies 1

2. History of Guillain-Barré syndrome (GBS)

   • Considered a precaution, not a contraindication 1
   • Risk-benefit assessment should be conducted
   • Benefits may outweigh risks for those at high risk of COVID-19 complications 1

3. Pregnancy

   • Not a contraindication for mRNA COVID-19 vaccines 1
   • Pregnant women meet criteria as a prioritized group for vaccination 1
   • Live attenuated vaccines may be contraindicated in pregnancy 1

Risk Assessment and Management

Risk Stratification

1. High risk for adverse reaction:

   • Documented anaphylaxis to previous COVID-19 vaccine dose
   • Confirmed allergy to PEG or polysorbate by skin testing
   • Action: Avoid vaccination or consider alternative vaccine platform without the allergenic component

2. Moderate risk:

   • History of immediate allergic reaction to other vaccines or injectable therapies
   • Action: 30-minute observation period after vaccination

3. Standard risk:

   • No history of concerning allergic reactions
   • Action: Standard 15-minute observation period

Management of Potential Allergic Reactions

• Vaccination sites must be equipped to identify and manage anaphylaxis 2
• Staff should be trained in recognition and emergency management of severe allergic reactions
• Appropriate medications and equipment should be immediately available 2

Important Clinical Considerations

• The rate of anaphylaxis to COVID-19 mRNA vaccines is estimated at approximately 11.1 cases per million doses 1
• Most individuals with reported allergic reactions to the first dose can safely receive the second dose 3
• IgE-mediated anaphylaxis to PEG is rarely identified after COVID-19 mRNA vaccine reactions 4
• Skin testing for PEG and polysorbate can help identify individuals at risk, though its predictive value is still being studied 3

Common Pitfalls to Avoid

• Do not withhold vaccination based solely on history of allergies unrelated to vaccines or their components
• Do not assume that all allergic-type symptoms following vaccination represent true allergic reactions
• Do not overlook the importance of having emergency medications and equipment readily available at vaccination sites
• Do not confuse contraindications with precautions - many conditions that were previously considered contraindications are now recognized as precautions

Remember that the benefits of COVID-19 vaccination generally outweigh the risks for most individuals, and decisions should be based on the most current evidence and individual risk assessment.