Which flu vaccine can a 55-year-old with a history of hives after consuming eggs safely receive: Inactivated Influenza Vaccine (IIV), Live Attenuated Influenza Vaccine, or High-Dose Influenza Vaccine?

Influenza Vaccination for a 55-Year-Old with Hives After Egg Consumption

A 55-year-old with a history of hives (urticaria only) after egg consumption can safely receive any age-appropriate influenza vaccine—including inactivated influenza vaccine (IIV), high-dose IIV, or recombinant influenza vaccine (RIV)—without any special precautions beyond standard vaccination protocols. 1, 2

Recommended Vaccine Options

All Standard Vaccines Are Safe

• Any licensed, age-appropriate influenza vaccine can be administered to patients who develop only hives after egg exposure, without special precautions. 1, 2
• This includes standard-dose IIV (trivalent or quadrivalent), high-dose IIV, cell culture-based IIV (ccIIV), and recombinant influenza vaccine (RIV). 3
• The Centers for Disease Control and Prevention (CDC) Advisory Committee on Immunization Practices (ACIP) explicitly states that hives-only egg allergy does not require any modifications to standard vaccination procedures. 1, 2

Specific Vaccine Considerations for This Patient

Inactivated Influenza Vaccine (IIV):

• Standard-dose IIV is completely appropriate and safe for this 55-year-old patient with hives-only egg allergy. 3
• No skin testing, divided dosing, or extended observation period is required. 1, 2
• Only the standard 15-minute post-vaccination observation for syncope is recommended. 2

High-Dose Influenza Vaccine:

• High-dose IIV3 (Fluzone High-Dose) is approved for persons aged ≥65 years, so this 55-year-old patient does not meet the age indication. 3
• However, if this patient were ≥65 years old, high-dose IIV would be equally safe despite the egg allergy history. 3

Live Attenuated Influenza Vaccine (LAIV):

• LAIV is licensed for healthy nonpregnant persons aged 2-49 years. 4
• This 55-year-old patient is outside the approved age range for LAIV, making it inappropriate regardless of egg allergy status. 4

Alternative Egg-Free Options (If Preferred)

While not necessary for hives-only egg allergy, completely egg-free alternatives exist:

Recombinant Influenza Vaccine (RIV):

• RIV (FluBlok) is manufactured without eggs and carries no contraindication for egg allergy of any severity. 3, 1
• RIV is approved for persons aged ≥18 years, making it appropriate for this 55-year-old patient. 1
• The CDC recommends RIV as the preferred option for individuals with egg allergies, though it is not required for hives-only reactions. 1

Cell Culture-Based IIV (ccIIV):

• ccIIV (Flucelvax) contains minimal theoretical egg protein (maximum 1.7×10⁻⁸ μg/0.5 mL dose or <50 femtograms). 3, 1
• ccIIV can be administered to persons with hives-only egg allergy who are aged ≥18 years. 3

Critical Clinical Distinctions

Hives-Only vs. Severe Egg Allergy

• The key distinction is that this patient experienced only hives (urticaria) after egg consumption, not severe reactions. 1, 2
• Severe reactions include angioedema, respiratory distress, lightheadedness, recurrent vomiting, or reactions requiring epinephrine. 2
• Patients with severe egg allergy reactions can still receive any age-appropriate influenza vaccine, but administration must occur in a medical setting with supervision by providers capable of managing severe allergic reactions. 2

Evidence Supporting Safety

• Multiple studies have demonstrated the safety of influenza vaccination in egg-allergic patients, including those with severe egg allergy. 5, 6, 7, 8
• Approximately 4,315 patients have safely received 4,872 total doses of influenza vaccine, including 656 patients with severe egg allergy who received 740 doses without anaphylaxis. 8
• Research confirms that egg-allergic individuals are at no increased risk for allergic reactions compared to the general population. 8

Common Pitfalls to Avoid

• Do not delay vaccination due to egg allergy concerns when only hives have occurred. 1, 2
• Do not perform skin testing with the influenza vaccine before administration for hives-only egg allergy. 2, 6
• Do not use divided-dose protocols (e.g., 10% followed by 90% dosing), as these are no longer recommended for patients with egg allergy. 2, 6
• Do not restrict to egg-free vaccines only, as any age-appropriate vaccine is acceptable and safe. 1, 2
• Do not require extended observation periods beyond the standard 15 minutes recommended for all vaccines. 2

Practical Algorithm for This Patient

1. Confirm the reaction to eggs was limited to hives only (no respiratory symptoms, angioedema, or cardiovascular symptoms). 2
2. Select any age-appropriate influenza vaccine available (standard-dose IIV, ccIIV, or RIV). 1, 2
3. Administer the vaccine using standard protocols without special precautions. 1, 2
4. Observe for 15 minutes post-vaccination for syncope, as recommended for all vaccines. 2

The bottom line: This 55-year-old can receive standard inactivated influenza vaccine safely, but cannot receive live attenuated vaccine due to age restrictions or high-dose vaccine due to age indications, not because of the egg allergy.