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Am Fam Physician. 1998;58(4):863-864

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.

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.

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