In children at increased risk of allergy, concerns about allergic vaccine reaction and promotion of allergy development by standard immunizations lead to incomplete vaccination coverage. The following are “Recommendations for vaccination of children and adolescents at increased risk of allergy” based on the position paper of the German Society for Pediatric Allergology and Environmental Medicine (GPA). Potential allergen sources in vaccines (modified from).
| Active vaccine antigens | Toxoids, toxins |
| Other vaccine antigens (native, recombinant) | |
| Contaminants from culture media | Hen egg |
| Chicken embryo | |
| Horse serum | |
| Cell components of mice, monkeys, dogs. | |
| Other impurities | Latex |
| Additives | |
|
Amphotericin B |
| Gentamycin | |
| Kanamycin | |
| Neomycin | |
| polymyxin B | |
| Streptomycin | |
|
Formaldehyde |
| Sodium thimerfonate | |
| Octoxinol | |
| Thiomersal | |
| 2-Phenoxyethanol | |
|
Gelatin |
| Lactose | |
| Polysorbate 80/20 |
Do standard vaccinations for children and adolescents cause allergic reactions?
Data from several cohort studies do not show increased allergic sensitization to environmental allergens after pertussis vaccination or after MMR vaccination [see 1 below for literature]. Statement 1: Standard vaccinations do not promote the development of allergic diseases such as atopic dermatitis, bronchial asthma, and allergic rhinitis (hay fever)
Should children with allergic predisposition receive regular vaccinations?
Statement 2: Children with atopic predisposition, allergic sensitization without clinical symptoms, or allergic diseases such as atopic dermatitis, bronchial asthma, and hay fever should be vaccinated according to STIKO recommendations under standard conditions (standard vaccine, undivided dose, no mandatory follow-up period) (recommendation grade A). Statement 3: If subcutaneous immunotherapy is ongoing, vaccinations should be given during the maintenance phase and midway between 2 allergen administrations (recommendation grade B).
Vaccination in allergy to vaccine components
Chicken protein Vaccines whose viruses have been grown in chicken fibroblast cell culture (measles–mumps–rubella, rabies, TBE) contain at most trace amounts of chicken protein (nanograms). Children with anamnestically known chicken egg protein allergy can be vaccinated against measles, mumps and rubella without any special risk.The Robert Koch Institute recommends that only children with a clinically very severe form of chicken egg protein allergy (e.g. anaphylactic shock after consumption or only after contact with the smallest amounts of chicken egg protein) should be vaccinated under special protective measures and subsequent observation (if necessary in hospital). MMR VaccinationStatement 4: Children with manifest chicken egg protein allergy (skin reaction only) can be MMRvaccinated under standard conditions. Children with respiratory, circulatory, or gastrointestinal reactions should be vaccinated by a physician experienced in recognizing and treating anaphylactic reactions in children (undivided dose, minimum monitoring time 2 hours) (recommendation grade A). Some yellow fever and influenza vaccines are prepared using incubated chicken eggs. These may contain higher levels of chicken egg protein due to manufacturing. From an allergologic standpoint, if the reaction to chicken egg is exclusively cutaneous, vaccination with TIV can be done in the office (undivided dose, 2 hours follow-up); if there is a respiratory or gastrointestinal reaction to chicken egg, vaccination with TIV should be done by a physician experienced in treating anaphylactic reactions (undivided dose, 2 hours follow-up). Statement 5: Influenza Vaccination Children with manifest chicken egg protein allergy (skin reaction only) should be vaccinated with inactivated influenza vaccine (TIV, undivided dose, minimum follow-up 2 hours) (recommendation grade A).Children with respiratory, circulatory, or gastrointestinal reactions should be vaccinated by a physician experienced in recognizing and treating anaphylactic reactions in children (undivided dose, minimum monitoring time 2 hours) (recommendation grade A). Statement 6: Yellow Fever VaccinationChildren with manifest chicken egg protein allergy should receive yellow fever vaccination only after careful individual benefit-risk consideration (recommendation grade A). If vaccination is indicated, it should be given in cooperation with a physician experienced in recognizing and treating anaphylactic reactions in children in a fractionated manner under inpatient monitoring (recommendation grade A). Gelatine, yeast fungiIf clinically manifest allergy to admixtures is recommended to use a vaccine free of this. If this is not possible, fractionated vaccination can be given in an individual risk-benefit assessment analogous to the procedure described for yellow fever vaccination.
What allergy diagnostics are useful?
For general recommendations on allergologic diagnostics, see the topic “Allergy Diagnostics.” Please refer to Statements 7-9. Furthermore, an interval of at least 4 weeks since allergic vaccine reaction is recommended before skin testing. Statement 7: Skin testing to predict or exclude allergic reaction to a vaccine should not be performed without a previous clinical allergic reaction to a vaccine (recommendation grade B). Statement 8: Skin testing with vaccine or vaccine components after a previous clinical allergic reaction to a vaccine to minimize the risk of future vaccine reactions should be performed (Grade B). Statement 9: Determination of serum IgE against vaccine antigens to predict or diagnose allergic vaccine reactions should not be performed (recommendation grade B).
Procedure for suspected allergic reaction to vaccination
After allergic vaccination reaction, a risk-benefit assessment in discussion with the patient and parents is necessary before any diagnostic procedure in synopsis with the severity of the reaction. Diagnostics are useful only if further vaccinations with the appropriate vaccine antigen or potentially allergenic components contained in the vaccine are indicated . The first step in diagnostics is a careful anamnesis. Cardinal questions include time of onset of reaction (immediate type reaction – within 4 hours – or delayed type), extent (local or systemic), detailed description of clinical reaction, and identification of vaccine ingredients as possible triggers. In the case of delayed reaction, additional information is needed, especially to delineate possible other causes or cofactors. Statement 10: Allergic workup should follow anaphylactic vaccine reaction to minimize the risk for future anaphylactic reaction (recommendation grade A). Medical history information for suspected allergic vaccine reactions (modified from).
| Time |
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| Expansion |
|
| Symptoms |
|
| Duration |
|
| Regression |
|
| Cofactors |
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| Vaccination history |
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| Other known allergies/diseases |
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Statement 11: Follow-up vaccinations after anaphylactic vaccine reaction or after anaphylactic reaction against a vaccine component should be given under inpatient monitoring (i.v. access, fractionated dose, minimum monitoring time 2 hours after last partial dose) by a physician experienced in recognizing and treating anaphylactic reactions in children (recommendation grade A). If possible, the triggering allergen should be avoided (recommendation grade A).
Prevention and management of allergic vaccine reactions
Statement 12: In cases of unknown allergologic and vaccine history, previous allergic vaccine reactions and allergic reactions to components of the vaccine should be inquired about before vaccination (recommendation grade A). Statement 13: If there is an increased risk of allergic vaccination reactions, information about this risk should be provided in addition to the general vaccination information (recommendation grade A). Statement 14: If there is an increased risk for anaphylactic reaction to vaccination, follow-up for at least 2 hours should be provided (recommendation grade B). Statement 15: The administration of each vaccination requires professional qualifications and equipment for the treatment of potential anaphylactic reactions (recommendation grade A). Statement 16: Treatment of allergic reactions to vaccination is equivalent to treatment of systemic allergic reactions of other etiologies (Grade of Recommendation A). Statement 17: Delaying vaccination protection against potentially disabling or fatal diseases under the purported notion of preventing allergy or asthma is not justified (Grade of Recommendation A). Position paper conclusion: in summary, currently available data show no allergy-protective effect from delaying publicly recommended vaccinations.
