Influenza Vaccination in Patients with Egg Allergy and Hives
Patients who develop only hives after eating eggs can and should receive the influenza vaccine with specific safety precautions, including administration by a knowledgeable provider and 30-minute post-vaccination observation. 1, 2
Vaccination Protocol for Hives-Only Reactions
Direct Administration Approach
Administer any age-appropriate inactivated influenza vaccine (IIV) directly without dose splitting or skin testing, as these additional measures are no longer considered necessary 1, 2
Use inactivated influenza vaccine (IIV) rather than live attenuated influenza vaccine (LAIV) because the safety data supporting vaccination in egg-allergic patients specifically involved IIV formulations 1
The vaccine should be given by a healthcare provider familiar with the potential manifestations of egg allergy to ensure rapid recognition of any adverse reactions 1
Observe the patient for at least 30 minutes after vaccination for signs of allergic reaction 1, 2
Safety Requirements
All vaccines must be administered in settings where personnel and equipment for rapid recognition and treatment of anaphylaxis are available 1, 2
Ensure all vaccination providers are familiar with the office emergency plan and prepared to manage anaphylaxis if it occurs 1, 2
Important Distinctions: When to Refer
If the patient experienced more severe reactions beyond hives—such as angioedema, respiratory distress, lightheadedness, recurrent vomiting, or reactions requiring epinephrine—refer to an allergist before vaccination 1
These patients are at higher risk for systemic or anaphylactic reactions and require specialized evaluation before proceeding with vaccination 1
Alternative Vaccine Options
For adults aged 18-49 years with any severity of egg allergy, recombinant influenza vaccine (RIV) is an egg-free alternative that can be administered per usual protocol 1, 2
Cell culture-based influenza vaccines contain minimal egg protein (estimated maximum of 5×10⁻⁸ μg per 0.5 mL dose) and may be considered, though they are not licensed for children under 18 years 1
Clinical Context and Safety Data
Surveillance data from VAERS showed no disproportionate reporting of allergic reactions or anaphylaxis during the 2011-12 and 2012-13 influenza seasons after implementation of these recommendations, supporting the safety of this approach 1
Research studies have consistently demonstrated that patients with egg allergy, even those with significant reactions to egg ingestion, can safely receive influenza vaccine when appropriate precautions are followed 3, 4, 5
Common Pitfalls to Avoid
Do not unnecessarily withhold influenza vaccination from patients with hives-only egg allergy, as the benefits of protection against influenza outweigh the minimal risk of vaccine reaction 2
Do not perform skin testing with the vaccine or use divided-dose protocols for patients with hives-only reactions, as these measures are outdated and no longer recommended 1, 2
Do not assume all patients who report egg allergy are truly allergic—those who can eat lightly cooked eggs (such as scrambled eggs) without reaction are unlikely to be allergic and can receive the vaccine per usual protocol 1