What are the Centers for Disease Control and Prevention (CDC) recommendations for flu vaccination in a patient with a history of hives due to egg products without an anaphylactic response?

CDC Recommendations for Flu Vaccination in Patients with Hives-Only Egg Allergy

Patients with a history of hives as their only reaction to egg products should receive influenza vaccine with specific safety precautions, including administration by a knowledgeable provider and 30-minute post-vaccination observation. 1

Vaccination Protocol for Hives-Only Egg Allergy

Primary Recommendation

• Administer influenza vaccine to patients who experienced only hives after egg exposure 1, 2
• Use inactivated influenza vaccine (IIV) rather than live attenuated influenza vaccine (LAIV), as the safety data supporting this recommendation primarily involved IIV 1

Required Safety Measures

• The vaccine must be administered by a healthcare provider familiar with the potential manifestations of egg allergy 1, 2
• Observe the patient for at least 30 minutes after vaccination for signs of allergic reaction 1, 2
• Ensure vaccination occurs in a setting where personnel and equipment for rapid recognition and treatment of anaphylaxis are available 1, 2

Unnecessary Measures

• Special measures such as split-dose administration or vaccine skin testing are NOT necessary 1, 2
• This represents an important simplification from older protocols that required more complex approaches 1

Distinguishing Hives-Only from More Severe Reactions

Hives-Only Reactions (Can Receive Vaccine with Precautions)

• Isolated urticaria (hives) following egg exposure 1
• No systemic symptoms beyond skin manifestations 1

Severe Reactions (Require Specialist Referral)

Refer to an allergist before vaccination if the patient experienced: 1

• Angioedema (swelling beyond hives)
• Respiratory distress or wheezing
• Lightheadedness or hypotension
• Recurrent vomiting
• Any reaction requiring epinephrine or emergency medical intervention
• Reactions occurring immediately or within minutes to hours after egg exposure

Alternative Vaccine Options

For Adults 18-49 Years

• Recombinant influenza vaccine (RIV) is egg-free and may be used for patients with any severity of egg allergy in this age group 1, 2
• Cell culture-based inactivated influenza vaccine (ccIIV) contains minimal egg protein and is another option 1

For Patients Who Can Eat Cooked Eggs

• Patients who can eat lightly cooked eggs (e.g., scrambled eggs) without reaction can receive any age-appropriate influenza vaccine per usual protocol 1, 2
• Tolerance to baked egg products (bread, cake) does not exclude the possibility of egg allergy and should not be used as the sole criterion 1

Safety Evidence Supporting This Approach

Surveillance Data

• VAERS surveillance for the 2011-12 and 2012-13 influenza seasons showed no disproportionate reporting of allergic reactions or anaphylaxis after implementation of these recommendations 1
• Research studies involving over 4,000 patients with egg allergy, including 513 with severe reactions, reported no cases of anaphylaxis to influenza vaccine 1
• A study of 830 patients with confirmed egg allergy receiving adjuvanted H1N1 vaccine resulted in zero anaphylactic reactions 3

Ovalbumin Content

• Most inactivated influenza vaccines contain ≤1 μg/0.5 mL of ovalbumin, which has been shown to be well-tolerated 1
• Vaccines containing up to 0.7 μg/0.5 mL have been safely administered to egg-allergic patients 1

Critical Safety Considerations

Emergency Preparedness

• All vaccination providers must be familiar with their office emergency plan 1, 2
• Equipment and medications for treating anaphylaxis must be immediately available 1, 2
• Providers should be certified in cardiopulmonary resuscitation 2

Common Pitfall to Avoid

• Do not withhold influenza vaccination from patients with hives-only egg allergy 1, 2
• The risk of influenza-related morbidity and mortality outweighs the minimal risk of allergic reaction to the vaccine in this population 1, 2
• Previous conservative approaches that avoided vaccination in all egg-allergic patients are no longer recommended 1