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Measles, Mumps, Rubella Vaccine and Allergy to Egg

TO THE EDITOR: Table 3 of Dr. Anderson's article on food allergy¹ states that the measles, mumps, rubella (MMR) vaccine containing egg protein should be given only after skin testing and then only in dilute amounts. This is no longer the case. According to a 1995 study published in the New England Journal of Medicine,² a single dose of the MMR vaccine may be safely given even to those with severe egg hypersensitivity.

STEVEN LANG, M.D.
175 W. Cheyenne Rd.
Apt. 202
Colorado Springs, CO 80906

REFERENCES

1. Anderson JA. Milk, eggs and peanuts: food allergies in children. Am Fam Physician 1997;56:1370.
2. James JM, Burks AW, Roberson PK, Sampson HA. Safe administration of the measles vaccine to children allergic to eggs. N Engl J Med 1995;332: 1262-6.

IN REPLY: When writing an article on food allergy for a journal with a very large readership, it is prudent to take a conservative approach.

As I pointed out in Table 3, the egg protein in the measles, mumps, rubella (MMR) vaccine, as well as in the influenza vaccine, is tolerated in full dose without problems by most children who are highly allergic to egg protein.¹ This is consistent with findings in challenge studies that included some children proven to be allergic to egg who were given measles and MMR vaccine, as pointed out in the 1995 article by James,² referred to by Dr. Lang.

This view is also consistent with the opinion of the American Academy of Pediatrics 1994 Red Book: Report of the Committee on Infectious Disease, 23rd Edition, which was the current edition when my article was in preparation in 1996 and submitted for publication in January 1997. As pointed out in the 1994 Red Book, despite the proven safety of the measles vaccine in most children, "10 cases of immediate severe allergic reactions in children with a history of anaphylactic reactions to egg ingestion" had been reported when MMR vaccine was given.³

Furthermore, the 1994 Red Book advised, particularly in view of the recommendation of the package insert which was approved by the Food and Drug Administration (FDA), that continued skin testing of patients with a history of anaphylactic reactions after egg ingestion seemed "advisable." The caution relating to hypersensitivity to eggs in patients requiring the measles and rubella virus vaccine still remains in the 1998/52nd edition of the Physicians' Desk Reference (PDR), which advises against use of the measles vaccine in persons who are highly allergic to eggs.⁴

While my article was in press (January 1997 through October 1997), the 1997/24th edition of the Red Book was published.⁵ In this book, the recommendations concerning MMR vaccine containing egg protein changed. It was recommended that children who are allergic to egg protein be given MMR, measles or mumps vaccine in a single injection without previous skin testing. However, it was pointed out that "some experts" advocate a 90-minute waiting period for children allergic to egg protein who are given MMR vaccine and recommend that the vaccine be given in an office "with immediate availability of equipment for emergency medical treatment of anaphylaxis."

Considering the fact that the FDA-approved package insert/PDR advice recommending caution in the use of MMR vaccine in children who are allergic to egg protein still remains in place in 1998, I feel that the advice given in my 1997 article should remain the same.

After all is considered, the reader should recognize the following statement from the second title page of the 1997 Red Book: "The recommendations of this publication do not include an exclusive course of treatment or serve as a standard of medical care."

If the FDA-approved package insert/PDR advice concerning administration of vaccine containing egg protein changes in the future, I am one of those experts referred to in the 1997 Red Book who advocates a substantial waiting period under controlled conditions following the administration of MMR vaccine in children who are highly allergic to egg protein--with or without previous vaccine skin testing.

JOHN A. ANDERSON, M.D.
Division of Allergy & Clinical Immunology
Henry Ford Hospital and Medical Centers
1 Ford Place
Detroit, MI 48202

REFERENCES

1. Anderson JA. Milk, eggs and peanuts: food allergies in children. Am Fam Physician 1997;56:1365-74.
2. James JM, Burks AW, Roberson PK, Sampson HA. Safe administration of the measles vaccine to children allergic to eggs. N Engl J Med 1995;332: 1262-6.
3. American Academy of Pediatrics. 1994 Red Book: Report of the Committee on Infectious Diseases. 23rd ed. Elk Grove Village, Ill.: American Academy of Pediatrics, 1994:36-7,318.
4. Merck and Co. Inc.: M-R vaccine (Measles and Rubella Virus Vaccine, Live). Physicians' Desk Reference. 52nd ed. Montvale, N.J.: Medical Economics, 1998:1683.
5. American Academy of Pediatrics. 1997 Red Book: Report of the Committee on Infectious Diseases. 24th ed. Elk Grove Village, Ill.: American Academy of Pediatrics, 1997:32.

Tibiofibular Diastasis in the Injured Ankle

TO THE EDITOR: Dr. Wexler's article,¹ "The Injured Ankle," should have mentioned that tibiofibular diastasis, which is easily seen on the anteroposterior view of the ankle (compare with the normal side if necessary), is a common cause of "late" ankle sprain pain. Also, early magnetic resonance imaging (MRI) of the talus can help in the diagnosis of undisplaced talus dome fractures.

JACOB TOM, M.D.
LLOYD TOM, M.D.
Department of Radiology
Kaiser Permanente Medical Center
1505 N. Edgemont
Los Angeles, CA 90027

REFERENCE

1. Wexler RK. The injured ankle. Am Fam Physician 1998;57:474-80.

IN REPLY: I agree with Dr. Tom that tibiofibular diastasis is a cause of "late" ankle sprains. Not only may it be noticed on routine radiographs, but clinically it may be inferred on physical examination. Pain elicited by placing pressure on the distal portion of the tibiofibular complex can signal such a condition, and it can be confirmed with diagnostic imaging.

I disagree, however, with the suggestion that an "early" MRI is appropriate in the evaluation of ankle injury. The physical examination, history and radiographs are adequate initial components in the diagnosis of an injured ankle. Expensive diagnostic tests should be reserved for difficult and refractory cases.

RANDELL K. WEXLER, M.D.
Caren Way Family Health
55 Caren Ave.
Worthington, OH 43085

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Corrections

An incorrect statement was made in the article "High-Altitude Medicine" (April 15, 1998, p. 1907). On page 1913, the fifth sentence of the first full paragraph should have stated that the travel medicine literature uses room-air Paco₂ of greater than 50 mm Hg as a contraindication to airline travel without supplemental oxygen.

An incorrect trade name was included in the text and in Table 4 of the article "Management of Withdrawal Syndromes and Relapse Prevention in Drug and Alcohol Dependence" (July 1998, pp. 139 and 142). The correct trade name for chlordiazepoxide is Librium.

A text box in the article "Preterm Labor: Diagnosis and Treatment" (May 15, 1998, p. 2460) contained a dosage error. Dexamethasone, when given to a woman in preterm labor between 24 and 34 weeks of gestation, is administered in a dosage of 6 mg intramuscularly every 12 hours for two days.

Copyright 1998 by the American Academy of Family Physicians.
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The editors of AFP welcome input concerning topics of current medical interest and feedback in response to articles and other material published in AFP. Send letters to Jay Siwek, M.D., Editor, American Family Physician, 8880 Ward Pkwy., Kansas City, MO 64114; fax: 816-333-0303; e-mail: afplet@aafp.org. Please include your complete address, telephone number and fax number. Letters should be double-spaced, fewer than 500 words and limited to one table or figure and six references. Letters submitted for publication in AFP must not be submitted to any other publication. Letters pertaining to AFP subject matter must be received within two months of publication. Any financial associations or other possible conflicts of interest must be disclosed at time of submission. Submission of a letter constitutes transfer of copyright to the American Academy of Family Physicians. The editors reserve the right to edit correspondence to meet style and space requirements.

Copyright © 1998 by the American Academy of Family Physicians.
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