Choosing Wisely:

Don’t routinely avoid influenza vaccination in egg-allergic patients.

Rationale and Comments: Of the vaccines that may contain egg protein (measles, mumps, rabies, influenza and yellow fever), measles, mumps and rabies vaccines have at most negligible egg protein; consequently no special precautions need to be followed in egg-allergic patients for these vaccines. Studies in egg-allergic patients receiving egg-based inactivated influenza vaccine have not reported reactions; consequently egg-allergic patients should be given either egg-free influenza vaccine or should receive egg-based influenza vaccine with a 30-minute post-vaccine observation period. Egg-allergic patients receiving the yellow fever vaccine should be skin tested with the vaccine and receive the vaccine with a 30-minute observation period if the skin test is negative. If positive, the vaccine may be given in graded doses with appropriate medical observation. Egg protein is present in influenza and yellow fever vaccines and in theory could cause reactions in egg-allergic patients. However, in 27 published studies collectively 4,172 patients with egg allergy received 4,729 doses of egg-based inactivated influenza vaccine with no cases of anaphylaxis, including 513 with severe egg allergy who uneventfully received 597 doses. The Center for Disease Control and Prevention’s Advisory Committee on Immunization Practices recommends that egg-allergic persons receive inactivated influenza vaccine as a single dose without prior vaccine skin testing and be observed for 30 minutes afterwards for any possible allergic reaction. If the reaction to the ingestion of eggs was hives only, the vaccine can be administered in a primary care setting, whereas if the reaction to the ingestion of eggs was more severe, the vaccine should be administered in an allergist/immunologist’s office. Two new inactivated influenza vaccine not grown in eggs have been approved for patients 18 years and older: Flucelvax, prepared from virus propagated in cell culture, and Flublok, recombinant hemagglutinin proteins produced in an insect cell line. For egg-allergic patients 18 years of age and older, either egg-based inactivated influenza vaccine can be used with the precautions above or egg-free inactivated influenza vaccine can be used. Measles and mumps vaccines (and Purified Chick Embryo Cell rabies vaccine) are grown in chick embryo fibroblast cultures and contain negligible or no egg protein. Thus, measles, mumps, and rubella and Purified Chick Embryo Cell rabies vaccine can be administered to egg-allergic recipients in the usual manner. Per the Yellow Fever vaccine package insert, egg-allergic recipients should be skin tested with the vaccine prior to administration. If negative, the vaccine can be given in the usual manner, but the patient should be observed for 30 minutes afterward. If the vaccine skin test is positive, the vaccine can be given in graded doses under appropriate medical observation.
Sponsoring Organizations:
  • American Academy of Allergy, Asthma and Immunology
  • Sources:
  • Advisory Committee on Immunization Practices
  • Disciplines:
  • Allergy and immunologic
  • Preventive Medicine
  • References: • Des Roches A, Paradis L, Gagnon R, Lemire C, Bégin P, Carr S, Chan ES, Paradis J, Frenette L, Ouakki M, Benoît M, De Serres G; PCIRN (Public Health Agency of Canada/Canadian Institutes of Health Research Influenza Research Network). Egg-allergic patients can be safely vaccinated against influenza. J Allergy Clin Immunol. 2012 Nov;130(5):1213–1216.
    • Centers for Disease Control and Prevention (CDC). Prevention and control of influenza with vaccines: recommendations of the Advisory Committee on Immunization Practices (ACIP)–United States, 2012–13 influenza season. MMWR Morb Mortal Wkly Rep. 2012 Aug 17;61(32):613–8.
    • FLUCELVAX (Novartis) Package Insert. 2012.
    • FLUBLOK (Protein Sciences) Package Insert. 2013.
    • American Academy of Pediatrics. Red Book: 2012 report of the Committee on Infectious Diseases. Pickering LK, ed. 29th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2012. 936 p.
    • Kelso JM, Greenhawt MJ, Li JT, Nicklas RA, Bernstein DI, Blessing-Moore J, Cox L, Khan D, Lang DM, Oppenheimer J, Portnoy JM, Randolph CR, Schuller DE, Spector SL, Tilles SA, Wallace D. Adverse reactions to vaccines practice parameter 2012 update. J Allergy Clin Immunol. 2012 Jul;130(1):25–43.
    • YF-VAX (Sanofi Pasteur) Package Insert. 2010.

    Email Alerts

    Don't miss a single issue. Sign up for the free AFP email table of contents.

    Sign Up Now