Measles, mumps, and rubella vaccination in a child with suspected egg allergy
BMJ 2011; 343 doi: https://doi.org/10.1136/bmj.d4536 (Published 03 August 2011) Cite this as: BMJ 2011;343:d4536
All rapid responses
We read with interest the practice review by Rolfe and Sheikh on
measles, mumps and rubella (MMR) vaccination in suspected egg allergy [1],
citing recent British Society for Allergy and Clinical Immunology
guidelines which recommend that all children with egg allergy should
receive the MMR [2]. However, these guidelines also recommend that an
allergy specialist should guide the provision of other egg-containing
vaccines (including Influenza and Yellow fever), for which the risk-
benefit is less clear [2].
Several serious travel-related diseases are preventable by vaccines
containing egg antigen, however limited data on the safety of
administration of these vaccines to egg allergic individuals are available
to inform risk-benefit analysis [3, 4]. For ten years at our UK hospital-
based travel medicine clinic we have immunised individuals referred with
suspected egg allergy based on a clinical protocol that involves:
1. Detailed clinical assessment of the nature of the allergy and the
risk of disease exposure by a specialist in Travel Medicine and Infectious
Diseases.
2. Testing for serum egg-white specific IgE guided by the clinical
presentation.
3. Immunisation protocol based on risk assessment; with high-risk
individuals (history of anaphylaxis or strongly positive specific IgE)
receiving prophylactic intravenous access +/- 20% test-doses
intradermally. In low-risk individuals, immunisation proceeds as normal
(although advanced resuscitation facilities are present) with a period of
post-dose clinical observation.
From 2000-2010 we vaccinated 14 individuals (12 with suspected egg
allergy, 2 with a reported history of allergic reactions to the egg-
protein containing purified chick embryo rabies vaccine) aged 18-43 years.
11/14 underwent radio allergosorbent tests (RAST) for egg-white specific
IgE, and 4/11 had a positive RAST (two moderate-level, one high-level, one
extremely high-level). 12/14 individuals were prophylactically cannulated
and 3/14 received an intradermal test dose. Of these, one individual with
an extremely high-level RAST experienced an immediate urticarial reaction
to the test dose, precluding full dose administration. Another individual
(with high-level RAST) had a minor local reaction that did not prohibit
full dose administration. Of the 14 egg-allergic patients, a total of 10
(including 2/4 with positive RAST) received egg-containing vaccines
without major adverse events. The other 4 patients received non egg-
containing vaccines.
Overall, there was a low frequency of serious allergic reactions in
this cohort of individuals with suspected egg allergy referred for
specialist-guided immunisation. The use of an intradermal test-dose may
have down-selected one individual with proven egg allergy at higher risk
of more serious systemic reactions [3]. We conclude that under
appropriately supervised and monitored conditions, such as those described
here, individuals with egg allergy can be vaccinated without excessive
risks, and therefore egg allergy should not necessarily represent a
barrier to receiving egg-containing immunisations against potentially life
-threatening vaccine-preventable diseases.
References:
1. Rolfe, A. and A. Sheikh, Measles, mumps, and rubella vaccination
in a child with suspected egg allergy. BMJ, 2011. 343: p. d4536.
2. Clark, A.T., et al., British Society for Allergy and Clinical
Immunology guidelines for the management of egg allergy. Clinical and
experimental allergy : journal of the British Society for Allergy and
Clinical Immunology, 2010. 40(8): p. 1116-29.
3. Roukens, A.H., et al., Reduced intradermal test dose of yellow
fever vaccine induces protective immunity in individuals with egg allergy.
Vaccine, 2009. 27(18): p. 2408-9.
4. Chino, F., et al., Skin reaction to yellow fever vaccine after
immunization with rabies vaccine of chick embryo cell culture origin.
Japanese journal of infectious diseases, 1999. 52(2): p. 42-4.
Competing interests: No competing interests
We welcome the article by Rolfe and Sheikh (1) and hope that it
reduces the numbers of egg allergic children referred to hospital to have
their MMR vaccine. Unfortunately the authors stated "Children who have
had previous serious reactions to any vaccine should be vaccinated under
hospital supervision" without any further clarification. How would they
define a serious reaction? For example, if this included a convulsion
after the third set of primary immunisations there would be little point
in immunising in hospital against MMR as any convulsion is likely to occur
5-10 days after the vaccine. It may have been more appropriate to suggest
that after a serious reaction to a vaccine, a child should be referred for
expert advice regarding further vaccinations. This would be primarily for
advice, but it would usually be to go ahead with further vaccinations.
(1) Rolfe A, Sheikh A. Measles, mumps, and rubella vaccination in a child
with suspected egg allergy. BMJ 2011; 343:d4536 doi: 10.1136/bmj.d4536.
Competing interests: No competing interests
Re:Measles, mumps, and rubella vaccination in a child with suspected egg allergy
We thank Duncan et al and Elliman et al for their welcome and
constructive responses to our article.
With respect to the point raised by Elliman et al, the word
constraints of the article constrained any detailed discussion about the
types of vaccine related reactions that may warrant a specialist
assessment/vaccination under specialist supervision. In any case, due to
the array of possible adverse reactions to various vaccinations it would
be impractical and ill-advised to attempt to provide any exhaustive list.
Rather, given that GPs and their teams have considerable experience with
vaccinating infants, we suggest that any reactions that cause clinicians
undue concern should be discussed with a specialist colleague before
administration of further vaccinations. We agree that in the majority of
cases it will ultimately prove safe to proceed with further vaccinations.
Competing interests: No competing interests