The Risk of Allergic Reaction to SARS-CoV-2 Vaccines and Recommended Evaluation and Management: A Systematic Review, Meta-Analysis, GRADE Assessment, and International Consensus Approach

Allergy-like nocebo events reported with COVID-19 vaccines: a case control study

BACKGROUND

Allergy-like symptoms after COVID-19 vaccination are frequently reported, though true allergic reactions are rare. Clinical trials suggest many reported symptoms may reflect nocebo effects. This study aimed to characterize nocebo responses and identify associated factors.

RESEARCH DESIGN AND METHODS

A case-control study was conducted using pharmacovigilance records and a cross-sectional questionnaire. Cases were defined as patients reporting allergy-like symptoms without anaphylaxis; controls reported reactogenicity or localized reactions. Data on demographics, medical history, vaccinations, and psychological factors were analyzed using multivariate logistic regression to identify risk factors associated with nocebo effects.

RESULTS

Among 1038 participants, 320 were nocebo cases and 718 were controls. Cases frequently reported cutaneous (71.8%) and respiratory (38.8%) symptoms, with 43.4% occurring after the first dose. Nocebo responses were positively associated with a history of allergy (OR 1.78, 95% CI: 1.32-2.4) and COMIRNATY vaccine (OR 1.60, 95% CI: 1.20-2.14), and negatively correlated with perceived vaccine effectiveness (OR 0.93, 95% CI: 0.88-0.98).

CONCLUSIONS

The nocebo effect appears to differ by vaccine type and is more common in individuals with a history of allergy and lower perceived vaccine effectiveness. While further research is needed to validate these findings, this underscores the importance of clear, evidence-based communication to reduce nocebo responses.

Adverse Events Following Vaccines: From Detection to Research Translation

Vaccines are lifesaving interventions that reduce the morbidity and mortality of disease. Fortunately, serious adverse events with vaccination are uncommon, but they must promptly be recognized and evaluated to assess and clarify the safety of future administration, a process that the public must understand in order to feel safe in receiving vaccines. In this article, we provide a review of vaccine development, discuss the process by which safety is ensured, and describe key adverse events associated with their administration. We review in detail existing mechanisms for reporting these events and assessing them following recovery, as well as communication related to vaccine safety. We also describe barriers to vaccination, such as nocebo effects and antivaccination groups, and use lessons learned from the successful development of COVID-19 vaccines during the recent pandemic to define future opportunities and directions for vaccine safety.

Outcomes of pediatric patients with suspected allergies to COVID-19 vaccines

Background

Adverse effects following immunizations (AEFIs) can contribute to vaccine hesitancy.

Objective

We evaluated clinical outcomes of AEFIs subsequent to administration of the coronavirus disease 2019 (COVID-19) vaccine at 2 pediatric allergy centers.

Methods

Data on pediatric patients referred for COVID-19 AEFI concerns between March 2021 and October 2022 were reviewed. The collected data included patient demographics, clinical characteristics, outcomes of prior COVID-19 vaccination, recommendations after consultation, and outcomes of revaccination.

Results

The 163 patients were separated into 2 groups based on the absence (n = 89 [54.6%]) or presence (n = 74 [45.4%]) of prior COVID-19-related AEFIs. The most common reason for referral without a prior AEFI was another suspected drug allergy (n = 58 [35.6%]). All patients in this group were recommended for COVID-19 vaccination. Of the 163 patients, 82 (92.1%) proceeded with vaccination, with 77 of them (93.9%) tolerating vaccination. Most of those with a prior COVID-19-related AEFI had a delayed cutaneous reaction (n = 60 [37.0%]); 1 patient (0.6%) had suspected anaphylaxis. In this group, 6 (8.1%) were advised to postpone COVID-19 vaccination until their debilitating skin conditions had improved in response to further treatment, whereas 45 (77.6%) tolerated subsequent vaccination to the same or an alternate COVID-19 vaccine type. The most common AEFI on revaccination was urticaria (in 8 of 11 patients [72.7%]). AEFI on revaccination was significantly associated with a history of spontaneous urticaria or angioedema (relative risk = 3.6 [95% CI = 1.30-9.99]; P = .020) and urticaria following COVID-19 vaccination previously (relative risk = 4.12 [95% CI = 1.22-13.87]; P = .017).

Conclusions

Children with a history of urticaria or angioedema related or unrelated to prior COVID-19 vaccination were at higher risk of a COVID-19-related AEFI on revaccination, although most were able to complete the vaccination series under the management of our immunology/allergy service.

COVID-19 vaccination: challenges in the pediatric population

Vaccination is considered to be one of the most effective means of protecting individuals and populations from the risks associated with exposure to various pathogens. The COVID-19 pandemic, caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), affected people of all ages worldwide. In response, several pharmaceutical companies rapidly leveraged their resources to develop vaccines within a very short period of time, leading to the introduction of new, improved, and combination vaccines for community-wide immunization. This review aims to provide a summary of the available literature on the efficacy and safety of COVID-19 vaccines in the pediatric population ranging from 0 to 18 years. An analysis of recent published studies reveals that the majority of clinical trials have reported a sustained immune response following COVID-19 vaccination in children across various age groups worldwide. The majority of the authors highlighted the effectiveness and safety of immunization schedules in children and adolescents. The population-level efficacy of this vaccination remains to be determined, provided that the benefits outweigh the potential risks. Long-term side effects must still be monitored to enable the development of safer and more effective vaccines for future pandemics.

Cordyceps militaris-Derived Bioactive Gels: Therapeutic and Anti-Aging Applications in Dermatology

Cordyceps militaris is a medicinal mushroom widely utilized in traditional East Asian medicine, recognized for its diverse therapeutic properties. This review explores the potential of C. militaris-derived bioactive gels for applications in dermatology and skincare, with a particular focus on their therapeutic and anti-aging benefits. In response to the rising incidence of skin cancers and the growing demand for natural bioactive ingredients, C. militaris has emerged as a valuable source of functional compounds, including cordycepin, polysaccharides, and adenosine. These compounds exhibit multiple bioactivities, including apoptosis induction, cell cycle arrest, and anti-inflammatory effects, which have been shown to be particularly effective against melanoma and other skin cancers. Additionally, the antioxidant properties of C. militaris enhance skin resilience by scavenging reactive oxygen species, reducing oxidative stress, and promoting collagen synthesis, thereby addressing skin health and anti-aging requirements. The potential for incorporating C. militaris compounds into gel-based formulations for skincare is also examined, either as standalone bioactives or in combination with synergistic ingredients. Emphasis is placed on the necessity of clinical trials and standardization to establish the safety, efficacy, and reproducibility of such applications. By providing a safer alternative to synthetic agents, C. militaris-derived bioactive gels represent a promising advancement in dermatology and skincare.

Occupational anaphylaxis: A Position Paper of the German Society of Allergology and Clinical Immunology (DGAKI)

BACKGROUND

Anaphylaxis is a systemic allergic reaction that is potentially life-threatening. Occupational anaphylaxis is an anaphylaxis that occurs in an occupational context. In this position paper, we propose diagnostic criteria for occupational anaphylaxis and provide an overview of the current state of knowledge in terms of prevalence, triggers, prevention, and management.

RESULTS

The most common triggers of occupational anaphylaxis include Hymenoptera venoms, followed by food and drugs. Chemicals, bites or contact with animals (mammals/snakes/insects) and natural rubber latex are far less common. Occupations at risk for occupational anaphylaxis are therefore beekeepers, outdoor workers, or those who handle food as well as healthcare workers. The route of contact, intensity, and frequency of exposure, type of allergen, and the simultaneous occurrence of co-factors determine the clinical manifestation. A detailed medical history is required to confirm the diagnosis of anaphylaxis and to identify the trigger. Both skin tests and the determination of specific IgE are recommended, but only very few commercially available and quality-tested allergens are available that can be examined using both test methods. Preventive measures are based on avoiding further exposure or, if necessary, replacing a working substance. A written emergency plan and the prescription of an adrenaline autoinjector as well as instructions for its use are mandatory. Allergen immunotherapy is recommended for systemic Hymenoptera venom allergy. Depending on the national healthcare systems, patients with occupational anaphylaxis must be reported to the accident insurance.

CONCLUSION

Occupational anaphylaxis is very rare. We recommend educational measures and generally standardized recording of occupational anaphylaxis for occupations with an increased risk of anaphylaxis.

Relative Effectiveness of the NVX-CoV2373 Vaccine Compared With the BNT162b2 Vaccine in Adolescents

This retrospective matched cohort study evaluated the efficacy of 2 doses of NVX-CoV2373 compared with that of BNT162b2 vaccines in preventing severe acute respiratory syndrome coronavirus 2 infection in adolescents. We analyzed 13-week risk differences and ratios between these 2 vaccines. The study included 465 NVX-CoV2373 and 465 BNT162b2 recipients. Throughout the follow-up period, 4.1% of NVX-CoV2373 recipients and 2.8% of BNT162b2 recipients contracted the severe acute respiratory syndrome coronavirus 2 infection. The incidence risk ratio for NVX-CoV2373 compared with that for BNT162b2 was calculated at 1.46 (95% CI 0.68-3.22; P = 0.296). While our findings suggest noninferiority between the 2 vaccines, further research is needed to comprehensively assess their effectiveness in real-world settings. Our study highlights the critical need for vigilant vaccine surveillance and monitoring efforts to ensure informed decision-making and public health protection.

Revaccination outcomes among adolescents and adults with suspected hypersensitivity reactions following COVID-19 vaccination: A Canadian immunization research network study

BACKGROUND

COVID-19 vaccination has been associated with anaphylaxis and hypersensitivity reactions. Infectious disease physicians and allergists in the Canadian Special Immunization Clinic (SIC) Network developed guidance for evaluating patients with adverse events following immunization (AEFI) including suspected hypersensitivity. This study evaluated management and adverse event recurrence following subsequent COVID-19 vaccinations.

METHODS

Individuals aged 12 years and older enrolled at participating SICs before February 28, 2023 who were referred for suspected or diagnosed hypersensitivity reaction following COVID-19 vaccination, or for prevaccination assessment of suspected allergy to a COVID-19 vaccine component were included. De-identified clinical assessments and revaccination data, captured in a centralized database, were analyzed. The Brighton Collaboration case definition (BCCD) for anaphylaxis (2023 version) was applied.

RESULTS

The analysis included 206 participants from 13 sites: 26 participants referred for pre-vaccination assessment and 180 participants referred for adverse events following COVID-19 vaccination (15/180 [8.3%] with BCCD confirmed anaphylaxis, 84 [46.7%] with immediate hypersensitivity symptoms not meeting BCCD, 33 [18.3%] with other diagnosed hypersensitivity reactions, and 48 [26.7%] participants with a final diagnosis of non-hypersensitivity AEFI). Among participants referred for AEFIs following COVID-19 vaccination, 166/180 (92.2%) were recommended for COVID-19 revaccination after risk assessment, of whom 158/166 (95.2%) were revaccinated (all with a COVID-19 mRNA vaccine). After revaccination, 1/15 (6.7%) participants with prior anaphylaxis, 1/77 (1.3%) with immediate hypersensitivity not meeting criteria for anaphylaxis and 1/24 (4.2%) with other physician diagnosed hypersensitivity developed recurrent AEFI symptoms that met the BCCD for anaphylaxis. All 26 participants referred pre-vaccination, including 9 (34.6%) with history of polyethylene glycol-asparaginase reactions, were vaccinated without occurrence of immediate hypersensitivity symptoms.

CONCLUSIONS

Most individuals in this national cohort who experienced a hypersensitivity event following COVID-19 vaccination and were referred for specialist review were revaccinated without AEFI recurrence, suggesting that specialist evaluation can facilitate safe revaccination.

RNA editing in response to COVID-19 vaccines: unveiling dynamic epigenetic regulation of host immunity

Background

COVID-19 vaccines are crucial for reducing the threat and burden of the pandemic on global public health, yet the epigenetic, especially RNA editing in response to the vaccines remains unelucidated.

Results

Our current study performed an epitranscriptomic analysis of RNA-Seq data of 260 blood samples from 102 healthy and SARS-CoV-2 naïve individuals receiving different doses of the COVID-19 vaccine and revealed dynamic, transcriptome-wide adenosine to inosine (A-to-I) RNA editing changes in response to COVID-19 vaccines (RNA editing in response to COVID-19 vaccines). 5592 differential RNA editing (DRE) sites in 1820 genes were identified, with most of them showing up-regulated RNA editing and correlated with increased expression of edited genes. These deferentially edited genes were primarily involved in immune- and virus-related gene functions and pathways. Differential ADAR expression probably contributed to RNA editing in response to COVID-19 vaccines. One of the most significant DRE in RNA editing in response to COVID-19 vaccines was in apolipoprotein L6 (APOL6) 3' UTR, which positively correlated with its up-regulated expression. In addition, recoded key antiviral and immune-related proteins such as IFI30 and GBP1 recoded by missense editing was observed as an essential component of RNA editing in response to COVID-19 vaccines. Furthermore, both RNA editing in response to COVID-19 vaccines and its functions dynamically depended on the number of vaccine doses.

Conclusion

Our results thus underscored the potential impact of blood RNA editing in response to COVID-19 vaccines on the host's molecular immune system.

Vaccines and allergy: Back to the right places

Hypersensitivity reactions represent one of the most common causes of hesitancy for adherence to national vaccination programs. The majority of hypersensitivity reactions after vaccination are mild, and anaphylaxis is reported to be rare, although it remains challenging to estimate the frequency attributed to each single vaccine, either because of the lower number of administered doses of less common vaccines, or the administration of simultaneous vaccine in most of the vaccination programs. Although literature remains scattered, international consensus guides clinicians in identifying patients who might need the administration of vaccines in protected environments due to demonstrated hypersensitivity to vaccine components or adjuvants. Here we provide the current guidance on hypersensitivity reactions to vaccines and on vaccination of children with allergy disorders.

An unexpected IgE anti-receptor binding domain response following natural infection and different types of SARS-CoV-2 vaccines

Humoral response to SARS-CoV-2 has been studied, predominantly the classical IgG and its subclasses. Although IgE antibodies are typically specific to allergens or parasites, a few reports describe their production in response to SARS-CoV-2 and other viruses. Here, we investigated IgE specific to receptor binding domain (RBD) of SARS-CoV-2 in a Brazilian cohort following natural infection and vaccination. Samples from 59 volunteers were assessed after infection (COVID-19), primary immunization with vectored (ChAdOx1) or inactivated (CoronaVac) vaccines, and booster immunization with mRNA (BNT162b2) vaccine. Natural COVID-19 induced IgE, but vaccination increased its levels. Subjects vaccinated with two doses of ChAdOx1 exhibited a more robust response than those immunized with two doses of CoronaVac; however, after boosting with BNT162b2, all groups presented similar IgE levels. IgE showed intermediate-to-high avidity, especially after the booster vaccine. We also found IgG4 antibodies, mainly after the booster, and they moderately correlated with IgE. ELISA results were confirmed by control assays, using IgG depletion by protein G and lack of reactivity with heterologous antigen. In our cohort, no clinical data could be associated with the IgE response. We advocate for further research on IgE and its role in viral immunity, extending beyond allergies and parasitic infections.

Preparing Patients for Oral Immunotherapy (PPOINT): International Delphi consensus for procedural preparation and consent

BACKGROUND

Despite the promise of oral immunotherapy (OIT) to treat food allergies, this procedure is associated with potential risk. There is no current agreement about what elements should be included in the preparatory or consent process.

OBJECTIVE

We developed consensus recommendations about the OIT process considerations and patient-specific factors that should be addressed before initiating OIT and developed a consensus OIT consent process and information form.

METHODS

We convened a 36-member Preparing Patients for Oral Immunotherapy (PPOINT) panel of allergy experts to develop a consensus OIT patient preparation, informed consent process, and framework form. Consensus for themes and statements was reached using Delphi methodology, and the consent information form was developed.

RESULTS

The expert panel reached consensus for 4 themes and 103 statements specific to OIT preparatory procedures, of which 76 statements reached consensus for inclusion specific to the following themes: general considerations for counseling patients about OIT; patient- and family-specific factors that should be addressed before initiating OIT and during OIT; indications for initiating OIT; and potential contraindications and precautions for OIT. The panel reached consensus on 9 OIT consent form themes: benefits, risks, outcomes, alternatives, risk mitigation, difficulties/challenges, discontinuation, office policies, and long-term management. From these themes, 219 statements were proposed, of which 189 reached consensus, and 71 were included on the consent information form.

CONCLUSION

We developed consensus recommendations to prepare and counsel patients for safe and effective OIT in clinical practice with evidence-based risk mitigation. Adoption of these recommendations may help standardize clinical care and improve patient outcomes and quality of life.

A randomized double-blinded trial to assess recurrence of systemic allergic reactions following COVID-19 mRNA vaccination

BACKGROUND

Systemic allergic reactions (sARs) following coronavirus disease 2019 (COVID-19) mRNA vaccines were initially reported at a higher rate than after traditional vaccines.

OBJECTIVE

We aimed to evaluate the safety of revaccination in these individuals and to interrogate mechanisms underlying these reactions.

METHODS

In this randomized, double-blinded, phase 2 trial, participants aged 16 to 69 years who previously reported a convincing sAR to their first dose of COVID-19 mRNA vaccine were randomly assigned to receive a second dose of BNT162b2 (Comirnaty) vaccine and placebo on consecutive days in a blinded, 1:1 crossover fashion at the National Institutes of Health. An open-label BNT162b2 booster was offered 5 months later if the second dose did not result in severe sAR. None of the participants received the mRNA-1273 (Spikevax) vaccine during the study. The primary end point was recurrence of sAR following second dose and booster vaccination; exploratory end points included biomarker measurements.

RESULTS

Of 111 screened participants, 18 were randomly assigned to receive study interventions. Eight received BNT162b2 second dose followed by placebo; 8 received placebo followed by BNT162b2 second dose; 2 withdrew before receiving any study intervention. All 16 participants received the booster dose. Following second dose and booster vaccination, sARs recurred in 2 participants (12.5%; 95% CI, 1.6 to 38.3). No sAR occurred after placebo. An anaphylaxis mimic, immunization stress-related response (ISRR), occurred more commonly than sARs following both vaccine and placebo and was associated with higher predose anxiety scores, paresthesias, and distinct vital sign and biomarker changes.

CONCLUSIONS

Our findings support revaccination of individuals who report sARs to COVID-19 mRNA vaccines. Distinct clinical and laboratory features may distinguish sARs from ISRRs.

Knowledge mapping and global trends of drug hypersensitivity from 2013 to 2023: A bibliometric analysis

BACKGROUND

Drug hypersensitivity is a major global public health issue with a significant increase in prevalence in populations. Here, we provide a deep insight into the frontier hotspot and future direction in the field of drug hypersensitivity.

METHODS

A knowledge map is portrayed based on publications related to drug hypersensitivity from Web of Science Core Collection using CiteSpace. Co-occurrence relationships of countries, institutes, authors, journals, references, and keywords are constructed. According to the co-occurrence relationships, hotspots and future trends are overviewed.

RESULTS

The United States ranked first in the world and China with the second highest publications was the only developing country. Torres, Mayorga, and Blanca were highly productive authors. Harvard University was the institution with the most research publications. Keywords co-occurrence analysis suggested applications in emerging causes, potential mechanisms, and clinical diagnosis as the research hotspots and development frontiers.

CONCLUSION

Research on drug hypersensitivity is in a rapid development stage and an emerging trend in reports of anaphylaxis to polyethylene glycols is identified. Developing algorithms for understanding the standardization process of culprit drugs, clinical manifestations, and diagnostic methods will be the focus of future direction. In addition, a better understanding of the mechanisms to culprit drugs with immunological precise phenotypic definitions and high-throughput platforms is needed.

Risk of SARS-CoV-2 breakthrough infection following NVX-CoV2373 and BNT162b2 vaccinations in Korean Adults: A population-based observational study

South Korea experienced a low prevalence of SARS-CoV-2 until the emergence of the omicron in early 2022, triggering a major community epidemic. To evaluate effectiveness of NVX-CoV2373 and BNT162b2 vaccines in Korean population, we conducted an observational study utilizing individual-level case data on laboratory-confirmed SARS-CoV-2 infection, along with vaccination record. A total of 47,078 recipients of NVX-CoV2373 vaccine and 7,561 recipients of BNT162b2 vaccine were eligible for the study. Thirty days post-second doses, COVID-19 rates were 7.9% (595 out of 7561) of NVX-CoV2373 recipients and 8.6 % (647 out of 7561) of BNT162b2 recipients experienced COVID-19. NVX-CoV2373 rates increased to 9.8 % and 11.2 % at 60 and 90 days, while BNT162b2 rates were 10.5 % and 11.3 % at the same intervals. The 22-weeks risk ratios for recipients of the NVX-CoV2373 vaccine as compared with recipients of the BNT162b2 vaccine were 1.11 (95 % CI, 0.99 to 1.25) for laboratory-confirmed SARS-CoV-2 infection. Continued monitoring is essential to evaluate the duration of protection across different vaccine platforms and schedules.

Coronavirus Disease 2019 mRNA Vaccination Appears Safe in Pediatric Patients With Hypersensitivity to Polyethylene Glycolated Escherichia coli L-asparaginase

Polyethylene glycol-asparaginase (PEGAsp) is an established component of acute leukemia therapy. Hypersensitivity reactions to PEGAsp occur in 10% to 15% of patients, with polyethylene glycol suggested as the antigenic culprit. As coronavirus disease 2019 (COVID-19) mRNA vaccines contain polyethylene glycol, the safety of administration of these vaccines to patients with prior PEGAsp hypersensitivity has been questioned. Between December 21, 2020 and March 3, 2022, 66 patients with acute leukemia and PEGAsp allergy received COVID-19 vaccination. No patients (0/66 0%, 95% CI: 0%-5.4%) experienced an allergic reaction to the vaccine. COVID-19 mRNA vaccination appears to be safe in pediatric and young adult patients with acute lymphoblastic leukemia with PEGAsp allergy.

Gastrointestinal reflux contributes to laryngopharyngeal symptoms that mimic anaphylaxis: COVID-19 vaccination experience

Background

The sensation of throat closure after vaccination is concerning for anaphylaxis and leads to vaccine hesitancy.

Objectives

We characterized patients who developed laryngopharyngeal symptoms (LPhS) after coronavirus disease 2019 (COVID-19) vaccination and assessed risk factors for these symptoms.

Methods

The study analyzed data from the COVID-19 vaccines adverse reactions registry (December 14, 2020, to June 13, 2022). Outcomes included the incidence of postvaccination LPhS and use of epinephrine. We identified and compared risk factors for COVID-19 postvaccination reactions between subjects with and without LPhS.

Results

A total of 158 subjects were enrolled onto the registry. LPhS were reported in 61 subjects (38.6%), of whom 52 (85.2%) received a subsequent dose. With initial vaccination, the use of epinephrine was higher in subjects with LPhS (20%) compared to those without (6%; P = .0094). Fifty-two subjects (85.2%) with LPhS received a subsequent COVID-19 vaccine dose with milder or no symptoms, and none needed treatment with epinephrine. Those with LPhS were more likely to have a history of drug allergies (P = .02), severe medication allergies (P = .03), gastroesophageal reflux disease (P = .018), and need for antireflux medications (P = .0085) compared to controls.

Conclusions

In our registry, postvaccination LPhS were common. LPhS can mimic anaphylaxis and lead to more frequent use of epinephrine. Gastroesophageal reflux disease was more frequent in these subjects. Patients with subjective throat closure sensation can safely receive subsequent vaccine doses with close observation and reassurance. LPhS are not unique to COVID-19 vaccines. Patient and provider education regarding the role of gastroesophageal reflux disease as a risk factor for LPhS with vaccination can improve vaccine uptake.

COVID-19 vaccine uptake and hesitancy in Chinese patients with asthma

OBJECTIVE

Both patients and physicians may be hesitant toward vaccination in patients with asthma, which may result in lower vaccine uptake. The aim of this work was to investigate the vaccination rate, the adverse reactions, as well as the factors associated with vaccine acceptance and hesitancy toward COVID-19 vaccination among asthmatic patients in Beijing.

METHODS

A multi-center, cross-sectional face-to-face survey was conducted in patients with asthma consecutively recruited from December 2021 to April 2022. The survey included asthma status, COVID-19 vaccine uptake and adverse reactions, and knowledge of and attitude toward COVID-19 vaccination.

RESULTS

A total of 261 patients were enrolled. The rate of COVID-19 vaccination during the study period was 73.6%, as compared to 87.64% in the general population in China. Patients who were currently working, had received other vaccines in the past, and had had no adverse reactions to other vaccines, showed a higher rate of COVID-19 vaccination. Patients believing that the vaccination of family members and colleagues had a positive impact on their decision to get vaccinated, were more likely to get the COVID-19 vaccines. The COVID-19 vaccination rate was lower in those with poorly monitored asthma and those using biologic therapies. The adverse effects of COVID-19 vaccines in asthmatic patients were similar to those in the general population.

CONCLUSION

The COVID-19 vaccination rate in asthmatic patients was lower than the general population in China. Active measures should be taken to control asthma and increase vaccination rates in these patients.

The Long Road of Long COVID: Specific Considerations for the Allergist/Immunologist

Long COVID (coronavirus disease 2019) syndrome, also known as post-acute sequelae of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, is a new disorder that can develop after an acute infection with the SARS-CoV-2 virus. The condition is characterized by multiorgan system involvement with a wide range of symptoms that can vary in severity from mild to debilitating. Some of the common symptoms associated with long COVID syndrome include cardiovascular issues such as heart palpitations and chest pain; thrombotic events (eg, blood clotting disorders); metabolic problems (eg, type 2 diabetes); dysautonomia; paroxysmal orthostatic tachycardia syndrome; myalgic encephalomyelitis/chronic fatigue syndrome; reactivation of the Epstein-Barr virus; the presence of autoantibodies; chronic spontaneous urticaria (hives); and connective tissue diseases. Whereas long COVID syndrome can affect individuals from various backgrounds, certain populations may be at higher risk such as individuals of Hispanic and Latino heritage, as well as those with low socioeconomic status, although approximately one-third of affected patients have no known risk factors or preexisting conditions. Many survivors of COVID-19 struggle with multiple symptoms, increased disability, reduced function, and poor quality of life. Whereas vaccination has been the most significant intervention able to decrease the severity of acute SARS-Cov2 infection and curtail deaths, limited data are available related to its modulating effect on long COVID necessitating the need for further investigation. Furthermore, several inflammatory pathways have been proposed for the pathogenesis of long COVID that are the targets for ongoing clinical studies evaluating novel pharmacological agents. The purpose of the present report is to review the many factors associated with long COVID with a focus on those aspects that have relevance to the allergist-immunologist.

Urticaria exacerbations and adverse reactions in patients with chronic urticaria receiving COVID-19 vaccination: Results of the UCARE COVAC-CU study

BACKGROUND

Concern about disease exacerbations and fear of reactions after coronavirus disease 2019 (COVID-19) vaccinations are common in chronic urticaria (CU) patients and may lead to vaccine hesitancy.

OBJECTIVE

We assessed the frequency and risk factors of CU exacerbation and adverse reactions in CU patients after COVID-19 vaccination.

METHODS

COVAC-CU is an international multicenter study of Urticaria Centers of Reference and Excellence (UCAREs) that retrospectively evaluated the effects of COVID-19 vaccination in CU patients aged ≥18 years and vaccinated with ≥1 dose of any COVID-19 vaccine. We evaluated CU exacerbations and severe allergic reactions as well as other adverse events associated with COVID-19 vaccinations and their association with various CU parameters.

RESULTS

Across 2769 COVID-19-vaccinated CU patients, most (90%) received at least 2 COVID-19 vaccine doses, and most patients received CU treatment and had well-controlled disease. The rate of COVID-19 vaccination-induced CU exacerbation was 9%. Of 223 patients with CU exacerbation after the first dose, 53.4% experienced recurrence of CU exacerbation after the second dose. CU exacerbation most often started <48 hours after vaccination (59.2%), lasted for a few weeks or less (70%), and was treated mainly with antihistamines (70.3%). Factors that increased the risk for COVID-19 vaccination-induced CU exacerbation included female sex, disease duration shorter than 24 months, having chronic spontaneous versus inducible urticaria, receipt of adenovirus viral vector vaccine, having nonsteroidal anti-inflammatory drug/aspirin intolerance, and having concerns about getting vaccinated; receiving omalizumab treatment and Latino/Hispanic ethnicity lowered the risk. First-dose vaccine-related adverse effects, most commonly local reactions, fever, fatigue, and muscle pain, were reported by 43.5% of CU patients. Seven patients reported severe allergic reactions.

CONCLUSIONS

COVID-19 vaccination leads to disease exacerbation in only a small number of CU patients and is generally well tolerated.

COVID-19 Treatments: Then and Now

The coronavirus disease 2019 (COVID-19) pandemic has evolved over the past 3+ years, and strategies to prevent illness and treat infection have changed over time. As COVID-19 transitions from a pandemic to an endemic infection, widespread nonpharmaceutical interventions such as mask mandates and governmental policies requiring social distancing have given way to more selective strategies for risk mitigation. Monoclonal antibody therapies used for disease prevention and treatment lost utility owing to the emergence of resistant viral variants. Oral antiviral medications have become the mainstay of treatment in nonhospitalized individuals, whereas systemic corticosteroids remain the cornerstone of therapy in those requiring supplemental oxygen. Emerging literature also supports the use of additional immune-modulating therapies in select admitted patients. Importantly, the COVID-19 pandemic highlighted both unprecedented research and development of medical interventions while also drawing attention to significant pitfalls in the global response. This review provides a comprehensive update in prevention and management of COVID-19.

An Update in COVID-19 Vaccine Reactions in 2023: Progress and Understanding

It has been 3 years since the coronavirus disease 2019 (COVID-19) pandemic was initially declared, and 2 years have passed since the first COVID-19 vaccines were introduced. Since then, 13.2 billion COVID-19 vaccine doses have been administered worldwide, largely with multiple doses of messenger RNA vaccines. Although mild local and systemic adverse effects after COVID-19 vaccination are common, serious adverse effects following immunization are rare, particularly when compared with the large number of vaccine doses administered. Immediate and delayed reactions are relatively common and present similarly to allergic and hypersensitivity reactions. Despite this, reactions generally do not commonly recur, cause sequelae, or contraindicate revaccination. In this Clinical Management Review, we provide an updated perspective of COVID-19 vaccine reactions, their spectrum and epidemiology, and recommended approaches to evaluation and management.

[Experiencia en la vacunación frente a la COVID-19 en personas con antecedentes de alergia.]

OBJECTIVE

A common consultation since the beginning of the vaccination campaign against COVID-19 was related to people with a history of allergy to drugs or other vaccines. The objective of the study was to describe what happened after the administration of the vaccine against COVID-19 in people with a history of moderate and severe allergy, vaccinated against COVID-19 in a Primary Care Emergency Center (PCEC).

METHODS

Observational descriptive study with sixty-four people with a history of moderate and severe allergy was carried out, vaccinated in PCEP, between May and October 2021, in the Barcelonés Nord and Maresme (Barcelona province), after assessment by primary care pharmacologists and pharmacists. The percentage of people with adverse events that occurred after vaccination during their stay in the PCEP, the types detected and severity were calculated. Subsequently, a telephone survey was conducted to determine patient satisfaction. A descriptive analysis (calculation of proportions) was performed.

RESULTS

The mean age of 49.7 years (from twelve to ninety-four years) and 90.6% were women. 87.5% of the administered vaccines were Comirnaty®. Adverse events occurring after vaccination were detected in fifteen patients (23.4%), of whom four (6.25%) were manifestations of hypersensitivity, all classified as mild. The reasons for vaccination were a history of allergy to NSAIDs (45.3%), antibiotics (32.8%), analgesics (17.2%), vaccines (28.1%), other substances (40.6%) and anaphylaxis (26.6%). The degree of general satisfaction was 9.11 (out of 10).

CONCLUSIONS

The percentage of patients with a history of anaphylaxis and allergic drug reactions who present hypersensitivity reactions to COVID-19 vaccines is 6.25% and all are mild.

The usability of testing skin reaction applying skin prick tests with Comirnaty (Pfizer, USA) vaccine in detecting the risk of developing post-vaccination immediate hypersensitivity response (anaphylaxis) after administration of this vaccine

Introduction

COVID-19 vaccines became a relevant element of prevention during COVID-19 pandemic. It is worth highlighting the importance of severe allergic post-vaccination reactions.

Aim

To evaluate the usability of skin reaction tests using skin prick tests with Comirnaty (Pfizer, USA) vaccine in risk detection of the post-vaccine immediate hypersensitivity reaction (anaphylaxis) after administration of this vaccine [PvIHR(A)].

Material and methods

The analysis embraces 102 people, 85 women and 17 men with a history of immediate hypersensitivity (anaphylaxis) [IHR(A)]. Detailed medical history was collected and skin prick tests were made among participants. The positive and negative test results were illustrated in Figure 1.

Results

As it stands in Table 1, considering all participants of the study, a positive result of the skin prick tests was obtained only in 2 cases, a negative result in 99 and 1 result was questionable. The two positive results were found in participants from a group with a previous PvIHR(A) in their past medical history and they decided not to get vaccinated. The one questionable result was of a person that had PvIHR(A) after administration of the first dose of Comirnaty vaccine (Pfizer, USA). This person decided to get vaccinated again and there was no PvIHR(A) observed.

Conclusions

COVID-19 vaccination involves a low risk of anaphylaxis. Purposefulness of providing the skin prick tests using the mRNA vaccine is questionable, due to their low sensitivity and low specificity.

COVID-19 mRNA vaccine, but not a viral vector-based vaccine, promotes neutralizing anti-type I interferon autoantibody production in a small group of healthy individuals

Coronavirus disease 2019 (COVID-19) vaccines are highly effective but also induce adverse events, in particular, autoimmunity. Findings from several studies revealed that patients with life-threatening SARS-CoV-2 infection had increased, pre-existing, neutralizing antibodies against type I interferons (IFNs). However, whether COVID-19 vaccination induces the anti-type I IFN antibody remains unclear. In the current study, we evaluated plasma levels of 103 autoantibodies against various human self-antigens and 16 antibodies against viral antigens in healthy individuals pre- and post-COVID-19 vaccination. Twelve participants received a COVID-19 mRNA vaccine (Pfizer-BioNTech or Moderna), and 8 participants received a viral vector-based vaccine (Janssen). All participants produced increased antibody levels against SARS-CoV-2 antigens following vaccination. Among the 103 autoantibodies, only plasma levels of IgG autoantibodies against type I IFNs increased in participants who received a mRNA vaccine (3/12), but not in those who received the viral vector-based vaccine (0/8) at postvaccination compared to pre-vaccination. Among the three individuals showing increased anti-IFN IgG following vaccination, both plasma samples and plasma-purified total IgGs showed a dose-dependent binding ability to IFN-α; two of the three showed neutralizing activity to IFN-α-2a-induced phosphorated STAT1 responses in human peripheral blood mononuclear cells postvaccination compared to baseline in vitro. Among the 103 autoantibodies tested, the COVID-19 mRNA vaccine, but not the viral vector-based vaccine, specifically induced neutralizing anti-type I IFN autoantibodies in a small group of healthy individuals (~10%). Findings from this study imply that COVID-19 mRNA vaccines may suppress IFN-mediated innate immunity and impair immune defense through induced autoimmunity in some healthy individuals, who may need to switch to another type of COVID-19 vaccine (e.g., a viral vector-based vaccine).

Updated guidance regarding the risk of allergic reactions to COVID-19 vaccines and recommended evaluation and management: A GRADE assessment and international consensus approach

This guidance updates 2021 GRADE (Grading of Recommendations Assessment, Development and Evaluation) recommendations regarding immediate allergic reactions following coronavirus disease 2019 (COVID-19) vaccines and addresses revaccinating individuals with first-dose allergic reactions and allergy testing to determine revaccination outcomes. Recent meta-analyses assessed the incidence of severe allergic reactions to initial COVID-19 vaccination, risk of mRNA-COVID-19 revaccination after an initial reaction, and diagnostic accuracy of COVID-19 vaccine and vaccine excipient testing in predicting reactions. GRADE methods informed rating the certainty of evidence and strength of recommendations. A modified Delphi panel consisting of experts in allergy, anaphylaxis, vaccinology, infectious diseases, emergency medicine, and primary care from Australia, Canada, Europe, Japan, South Africa, the United Kingdom, and the United States formed the recommendations. We recommend vaccination for persons without COVID-19 vaccine excipient allergy and revaccination after a prior immediate allergic reaction. We suggest against >15-minute postvaccination observation. We recommend against mRNA vaccine or excipient skin testing to predict outcomes. We suggest revaccination of persons with an immediate allergic reaction to the mRNA vaccine or excipients be performed by a person with vaccine allergy expertise in a properly equipped setting. We suggest against premedication, split-dosing, or special precautions because of a comorbid allergic history.

Effectiveness and Safety of COVID-19 Vaccinations: An Umbrella Meta-Analysis

Objectives: This umbrella meta-analysis aims to provide comprehensive and synthesized evidence regarding the effectiveness and safety of COVID-19 vaccinations based on current studies. Methods: Studies from the Cochrane Library, PubMed, and EMBASE, published before 10 December 2021, were included in the analysis. The pooled results of effectiveness and safety were estimated and shown in forest plots. Results: We included nineteen studies (fifteen studies regarding safety and nine regarding effectiveness) in the analysis. The mRNA vaccines, adenovirus vector vaccines, subunit vaccines, and inactivated vaccines were found to be effective; however, mRNA vaccines, adenovirus vector vaccines and subunit vaccines were associated with local adverse events and systemic events when compared with inactivated vaccines. Conclusion: Our study suggested that till date, COVID-19 vaccination is still a preferred pharmaceutical way to control the widespread pandemic. However, all reported adverse events should be revisited to provide further evidence for mass vaccinations.

Impact of SARS-CoV-2 Infection in Children with Asthma and Impact of COVID-19 Vaccination: Current Evidence and Review of the Literature

The clinical aspects of SARS-CoV-2 infection, as well as the COVID-19 vaccines' safety, efficacy and effectiveness in pediatric patients with asthma, are crucial to adapting clinical management in this fragile population and for prevention strategies. The aim of this narrative review was to evaluate the impact of SARS-CoV-2 infection in children with asthma and the impact of COVID-19 vaccination. Systematic research using the principal medical databases was conducted using specific search query strings from the early spreading of COVID-19 globally until March 2023; further relevant data were drawn from the main national and supranational institutions. No significant differences in SARS-CoV-2 incidence and morbidity were found in asthmatic pediatric patients compared to non-asthmatic ones; however, subjects with uncontrolled asthma were found to be at increased risk of developing a serious disease during SARS-CoV-2 infection. Regarding COVID-19 vaccines, accumulating data support their safety, efficacy and effectiveness on asthmatic children regardless of asthma severity. Further cohort-based studies are needed as the evidence of new epidemic waves caused by new viral variants makes the current knowledge outdated.

Provision of Food Allergy Care in the United Kingdom and United States: Current Issues and Future Directions

Food allergy (FA) is a growing issue worldwide. The United Kingdom and United States are high-income, industrialized countries with reported increases in FA prevalence over the past few decades. This review compares delivery of FA care in the United Kingdom and United States and each country's response to the heightened demand and disparities for FA services. In the United Kingdom, allergy specialists are scarce and general practitioners (GPs) provide most allergy care. Whereas the United States has more allergists per capita than the United Kingdom, there is still a shortage of allergy services owing to the greater reliance on specialist care for FA in America and wide geographic variation in access to allergist services. Currently, generalists in these countries lack the specialty training and equipment to diagnose and manage FA optimally. Moving forward, the United Kingdom aims to enhance training for GPs so they may provide better quality frontline allergy care. In addition, the United Kingdom is implementing a new tier of semi-specialized GPs and increasing cross-center collaboration through clinical networks. The United Kingdom and United States aim to increase the number of FA specialists, which is critical at a time of rapidly expanding management options for allergic and immunologic diseases requiring clinical expertise and shared decision-making to select appropriate therapies. While these countries aim to grow their supply of quality FA services actively, further efforts to build clinical networks and perhaps recruit international medical graduates and expand telehealth services are necessary to reduce disparities in access to care. For the United Kingdom in particular, increasing quality services will require additional support from the leadership of the centralized National Health Service, which remains challenging.

Identifying and Managing Those at Risk for Vaccine-Related Allergy and Anaphylaxis

Immediate hypersensitivity reactions to vaccines, the most severe of which is anaphylaxis, are uncommon events occurring in fewer than 1 in a million doses administered. These reactions are infrequently immunoglobulin E-mediated. Because they are unlikely to recur, a reaction to a single dose of a vaccine is rarely a contraindication to redosing. This narrative review article contextualizes the recent knowledge we have gained from the coronavirus 2019 (COVID-19) pandemic rollout of the new mRNA platform with the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccines within the much broader context of what is known about immediate reactions to other vaccinations of routine and global importance. We focus on what is known about evidence-based approaches to diagnosis and management and what is new in our understanding of mechanisms of immediate vaccine reactions. Specifically, we review the epidemiology of immediate hypersensitivity vaccine reactions, differential diagnosis for immune-mediated and nonimmune reaction clinical phenotypes, including how to recognize immunization stress-related responses. In addition, we highlight what is known about mechanisms and review the rare but important contribution of excipient allergies and specifically when to consider testing for them as well as other key features that contribute to safe evaluation and management.

Potentiating the Cross-Reactive IFN-γ T Cell and Polyfunctional T Cell Responses by Heterologous GX-19N DNA Booster in Mice Primed with Either a COVID-19 mRNA Vaccine or Inactivated Vaccine

Waning vaccine-induced immunity, coupled with the emergence of SARS-CoV-2 variants, has inspired the widespread implementation of COVID-19 booster vaccinations. Here, we evaluated the potential of the GX-19N DNA vaccine as a heterologous booster to enhance the protective immune response to SARS-CoV-2 in mice primed with either an inactivated virus particle (VP) or an mRNA vaccine. We found that in the VP-primed condition, GX-19N enhanced the response of both vaccine-specific antibodies and cross-reactive T Cells to the SARS-CoV-2 variant of concern (VOC), compared to the homologous VP vaccine prime-boost. Under the mRNA-primed condition, GX-19N induced higher vaccine-induced T Cell responses but lower antibody responses than the homologous mRNA vaccine prime-boost. Furthermore, the heterologous GX-19N boost induced higher S-specific polyfunctional CD4⁺ and CD8⁺ T cell responses than the homologous VP or mRNA prime-boost vaccinations. Our results provide new insights into booster vaccination strategies for the management of novel COVID-19 variants.

A practical guide to address reactions to vaccines in children

Currently available vaccines are safe, but, potentially, any vaccine can cause an allergic reaction and, albeit very rare, anaphylaxis can occur. Although its rarity, the precise diagnostic management of a suspected anaphylaxis postvaccination is of paramount importance due to the risk of a potentially serious reaction after re-exposure, while a misdiagnosis might lead to an increase in the number of children that interrupt vaccinations resulting in an unjustifiably individual and collective risk of loss of protection against immune preventable diseases. In the light that most cases of suspected allergy to a vaccine are not effectively confirmed in up to 85% of the cases referred for an allergy evaluation, patients can continue the vaccination schedule with the same formulation and tolerance of the booster doses. The patient assessment has to be done by an expert in the vaccine field, usually an allergist or an immunologist depending on the country, to select subjects at risk of allergic reactions and to perform the correct procedures for vaccine hypersensitivity diagnosis and management, in order to guarantee safe immunization practices. The aim of this review is to provide a practical guidance for the safe management of allergic children undergoing immunization procedures. The guide is referred both to the evaluation of children who have previously experienced a suspected allergic reaction to a specific vaccine and their management in case of further booster doses, and to children allergic to a component of the vaccine to be administered.

Pearls for practice from the 2022 joint task force drug allergy practice parameter

PURPOSE OF REVIEW

To review updated recommendations in the 2022 Drug Allergy Practice Parameters for the evaluation and management of drug hypersensitivity reactions.

RECENT FINDINGS

Adverse drug reactions have become increasingly prominent with the advent of new and emerging pharmacologic therapies. Hypersensitivity reactions encompass a significant proportion of adverse drug reactions and negatively impact both the individual patient and overall health system. Reactions are heterogeneous in presentation and may be immediate (onset of symptoms ≤6 h) or delayed (onset of symptoms >6 h to months) after drug exposure. The 2022 Drug Allergy Practice Parameter provides consensus-based statements for evaluation of hypersensitivity reactions to antibiotics, NSAIDs, cancer chemotherapies, immune checkpoint inhibitors, biologics, and excipients. In general, the guideline highlights the importance of patient history in elucidating the phenotype and severity of the index reaction. Drug challenge remains the gold standard for diagnosis and is increasingly favored over skin testing in patients with nonsevere, nonanaphylactic drug reaction histories.

SUMMARY

The 2022 Drug Allergy Practice Parameter provides an updated framework for physicians to reference in clinical practice when managing patients with drug hypersensitivity reactions.

Evaluation of association of anti-PEG antibodies with anaphylaxis after mRNA COVID-19 vaccination

BACKGROUND

The mechanism for anaphylaxis following mRNA COVID-19 vaccination has been widely debated; understanding this serious adverse event is important for future vaccines of similar design. A mechanism proposed is type I hypersensitivity (i.e., IgE-mediated mast cell degranulation) to polyethylene glycol (PEG). Using an assay that, uniquely, had been previously assessed in patients with anaphylaxis to PEG, our objective was to compare anti-PEG IgE in serum from mRNA COVID-19 vaccine anaphylaxis case-patients and persons vaccinated without allergic reactions. Secondarily, we compared anti-PEG IgG and IgM to assess alternative mechanisms.

METHODS

Selected anaphylaxis case-patients reported to U.S. Vaccine Adverse Event Reporting System December 14, 2020-March 25, 2021 were invited to provide a serum sample. mRNA COVID-19 vaccine study participants with residual serum and no allergic reaction post-vaccination ("controls") were frequency matched to cases 3:1 on vaccine and dose number, sex and 10-year age category. Anti-PEG IgE was measured using a dual cytometric bead assay (DCBA). Anti-PEG IgG and IgM were measured using two different assays: DCBA and a PEGylated-polystyrene bead assay. Laboratorians were blinded to case/control status.

RESULTS

All 20 case-patients were women; 17 had anaphylaxis after dose 1, 3 after dose 2. Thirteen (65 %) were hospitalized and 7 (35 %) were intubated. Time from vaccination to serum collection was longer for case-patients vs controls (post-dose 1: median 105 vs 21 days). Among Moderna recipients, anti-PEG IgE was detected in 1 of 10 (10 %) case-patients vs 8 of 30 (27 %) controls (p = 0.40); among Pfizer-BioNTech recipients, it was detected in 0 of 10 case-patients (0 %) vs 1 of 30 (3 %) controls (p >n 0.99). Anti-PEG IgE quantitative signals followed this same pattern. Neither anti-PEG IgG nor IgM was associated with case status with both assay formats.

CONCLUSION

Our results support that anti-PEG IgE is not a predominant mechanism for anaphylaxis post-mRNA COVID-19 vaccination.

[Reasons for allergology consultations prior to COVID-19 vaccination and their outcomes : Two-year experience of an allergy center in North Rhine-Westphalia]

BACKGROUND

To counteract the coronavirus disease 2019 (COVID-19) pandemic, several severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2) vaccines have been licensed since December 2020. Shortly after the start of the vaccination campaigns, occasional allergic reactions related to vaccines were described, thus, leading to concerns in many patients with a history of allergies. The aim of this work was to evaluate which anamnestic events represented a reason for an allergology work-up before COVID-19 vaccination. Furthermore, the results of the allergology diagnostics are described.

METHODS

We performed a retrospective data analysis of all patients who presented at the Center for Dermatology, Allergology and Dermatosurgery of the Helios University Hospital Wuppertal during the years 2021 and 2022 for allergology work-up prior to COVID-19 vaccination. Demographic data, allergological history, reason for the consultation in the clinic and results of allergology diagnostic tests including reactions after vaccination were included.

RESULTS

A total of 93 patients presented for allergology work-up with COVID-19 vaccines. In about half of the cases, the reasons for the presentation to the clinic were doubts and concerns about allergic reactions and side effects. In all, 26.9% (25/93) of the presented patients had not previously received a COVID-19 vaccine yet and 23.7% (22/93) of patients developed non-allergic reactions after prior COVID-19 vaccine (e.g., headache, chills, fever, malaise). Of the patients, 46.2% (43/93) were successfully vaccinated in the clinic due to a complex allergological history, while the remaining 53.8% (50/93) were subjected to outpatient vaccination in the vaccination practice. Only one patient with known chronic spontaneous urticaria developed a mild angioedema of the lips a few hours after vaccination; however, we do not consider this episode an allergic reaction to the vaccine due to the time delay.

CONCLUSION

Allergic reactions after COVID-19 vaccines are rare, but many patients with a positive medical history of allergies are concerned about allergic reactions after COVID-19 vaccination. Thus, public work by practicing allergologists is important during vaccination campaigns to meet the concerns and fears of the population, especially of patients with allergies in their medical history.

Evaluation of pediatric patients with suspected polyethylene glycol and polysorbate allergy before mRNA SARS-CoV2 vaccination

mRNA vaccines, particularly, have been associated with an increased risk of allergic reactions and rarely anaphylaxis. Although rare, vaccine reactions can cause significant anxiety and fear in the population, leading to indecision and vaccine refusal. This study aimed to retrospectively evaluate the role of polyethylene glycol (PEG) sensitivity in vaccination decision-making in pediatric patients at high risk of allergy or with suspected allergic reactions to the first dose of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) vaccine. Seventeen enrolled patients were found to have decreased readiness to receive the Coronavirus Disease 2019 (COVID-19) vaccine after developing hypersensitivity to multiple and/or injectable drugs. Skin testing was performed. A basophil activation test with PEG-2000 and 4000 was performed on three patients who were ineligible for skin prick tests. Nine patients with negative tests received the vaccine without complications. One patient had urticarial angioedema despite negative tests. Three patients with positive tests did not agree to desensitization with the mRNA vaccine, and one of them was vaccinated with the inactivated COVID-19 vaccine. Four patients recurred despite negative tests. The general recommendation for patients describing severe reactions to drugs, foods, and allergens, such as toxins that do not contain the adjuvants of the SARS-CoV-2 vaccines, is to be routinely vaccinated with safety precautions. Excipients such as PEG and polysorbate-80 used in COVID-19 vaccines could be potential allergens, but this hypothesis is unclear. The predictive values of these adjuvants for skin testing and in vitro testing are controversial. Further research is needed on the hypersensitivity reactions of adjuvants, the predictive values of skin tests, and etiopathogenesis.

Vaccine confidence among those living with allergy during the COVID pandemic (ACCORD): A scoping review

Background

Reports of allergic reactions to coronavirus disease 2019 (COVID-19) vaccines, coupled with an "infodemic" of misinformation, carry the potential to undermine confidence in the COVID-19 vaccines. However, no attempts have been made to comprehensively synthesize the literature on how allergic disease and fear of allergic reactions to the vaccines contribute to hesitancy.

Objectives

Our aim was to review the academic and gray literature on COVID-19 vaccine hesitancy and allergic reactions.

Methods

We searched 4 databases (CINAHL, PsycINFO, MEDLINE, and Embase) using a search strategy developed by content and methodologic experts. No restrictions were applied regarding COVID-19 vaccine type, country of study, or patient age. Eligible articles were restricted to 10 languages.

Results

Of the 1385 unique records retrieved from our search, 60 articles (4.3%) were included. Allergic reactions to the COVID-19 vaccine were rare but slightly more common in individuals with a history of allergic disease. A fifth of the studies (13 of 60 [22%]) discussed vaccine hesitancy due to possibility of an allergic reaction. Additionally, the present review identified research on details of vaccine-related anaphylaxis (eg, a mean and median [excluding clinical trial data] of 12.4 and 5 cases per million doses, respectively) and allergic reactions (eg, a mean and median [excluding clinical trial data] of 489 and 528 cases per million doses, respectively).

Conclusion

COVID-19 vaccine acceptance among individuals living with allergy and among those with no history of allergic disease may be affected by fear of an allergic reaction. Despite the low incidence of allergic reactions to the COVID-19 vaccine, fear of such reactions is one of the most commonly cited concerns reported in the literature.

Before and After: Attitude and Adverse Effects Induced by the First and Second Doses of mRNA BNT162b2 Vaccine among Healthcare Professionals in the First Weeks after Their Introduction in Poland

BACKGROUND

In the last days of December 2020, the SARS-CoV-2 virus vaccine BNT162b2 (Comirnaty, Pfizer-BioNTech) was introduced, for the first time, for wide use in Poland. According to the vaccination schedule, healthcare workers were the first to receive the vaccine. The aim of this study was to analyse the attitudes of those who were determined to be vaccinated, with particular reference to their concerns, attitudes towards vaccination advocacy and sources of knowledge on vaccination, as well as the incidence of adverse reactions.

METHODS

The study had a three-stage design. Respondents completed a self-administered questionnaire before receiving the 1st and 2nd vaccine doses and 2 weeks after receiving the 2nd dose. A total of 2247 responses were obtained (1340 responses in the first stage, 769 in the second and 138 in the third).

RESULTS

The main source of knowledge on vaccination was the Internet (32%; n = 428). Of the respondents, 6% (n = 86) reported anxiety before the 1st dose of the vaccine, which increased to 20% (n = 157) before the 2nd dose. A declaration of willingness to promote vaccination among their families was made by 87% (n = 1165). Among adverse reactions after the 1st dose of the vaccine, respondents most frequently observed pain at the injection site (n = 584; 71%), fatigue (n = 126; 16%) and malaise (n = 86; 11%). The mean duration of symptoms was 2.38 days (SD 1.88). After the 2nd dose of vaccine, similar adverse reactions-pain at the injection site (n = 103; 75%), fatigue (n = 28; 20%), malaise (n = 22; 16%)-predominated among respondents. Those who declared having had a SARS-CoV-2 virus infection (p = 0.00484) and with a history of adverse vaccination reactions (p = 0.00374) were statistically more likely to observe adverse symptoms after vaccination.

CONCLUSIONS

Adverse postvaccinal reactions are relatively common after Comirnaty vaccination but are usually mild and transient in nature. It is in the interest of public health to increase the knowledge of vaccine safety.

Anaphylaxis: Revision of the Brighton collaboration case definition

The Brighton Collaboration (BC) has formulated a number of case definitions which have primarily been applied to adverse events of special interest in the context of vaccine safety surveillance. This is a revision of the 2007 BC case definition for anaphylaxis. Recently, the BC definition has been widely used for evaluating reports of suspected anaphylaxis following COVID-19 vaccination. This has led to debate about the performance of the BC definition in comparison with those from the US National Institute of Allergy and Infectious Disease/Food Allergy Anaphylaxis Network (NIAID/FAAN) and the World Allergy Organization (WAO). BC convened an expert working group to revise the case definition based on their usual process of literature review and expert consensus. This manuscript presents the outcome of this process and proposes a revised case definition for anaphylaxis. Major and minor criteria have been re-evaluated with an emphasis on the reporting of observable clinical signs, rather than subjective symptoms, and a clearer approach to the ascertainment of levels of certainty is provided. The BC case definition has also been aligned with other contemporary and international case definitions for anaphylaxis.

mRNA COVID-19 Vaccine Anaphylaxis: Epidemiology, Risk Factors, and Evaluation

PURPOSE OF REVIEW

The COVID-19 vaccines have proved essential in our defense against the COVID-19 pandemic. However, concerns regarding allergic reactions to the vaccines persist to this day. Herein, we review the data regarding the frequency of allergic reactions to the COVID-19 vaccines, the epidemiology, and the management of patients reporting vaccine allergic reactions.

RECENT FINDINGS

Although initial reports emphasized a high risk of anaphylaxis to the COVID-19 vaccines, more recent data demonstrate similar rates of anaphylaxis to the COVID-19 vaccines as to other vaccines. Alternative explanations for increased rates of apparent allergic reactions are discussed, including the role for stress-related and nocebo responses. COVID-19 vaccines and mRNA vaccine technology are overwhelmingly safe and well-tolerated by most patients. Careful history and case review will enable the discerning physician to safely vaccinate most patients. Rare patients with objective signs and symptoms of anaphylaxis may be candidates for alternatives to vaccination including monoclonal antibodies.

Localized Delayed T-cell Mediated Hypersensitivity After mRNA SARS-CoV-2 Vaccination

Since the emergency authorization of SARS-CoV-2 vaccines, the medical literature has been investigating the management of allergic reactions to the vaccines. Anaphylaxis has been reported among a minority of vaccinated individuals, and many trials monitoring the safety profile of the vaccines have identified cases of benign cutaneous reactions. Typical features of delayed benign cutaneous hypersensitivity reactions include localized erythema, pruritus, and rash. However, reports have described rare cases of rash and atopy at sites apart from the injection site following vaccine delivery. We will discuss a unique case of delayed benign cutaneous hypersensitivity presenting in the lower extremity after an upper-extremity administration of an mRNA SARS-CoV-2. Additionally, we describe management strategies to guide clinicians who encounter similar vaccine-induced hypersensitivity reactions.

Increasing the COVID-19 immunization rate through allergy testing

BACKGROUND

Vaccination of the population is required to combat the COVID-19 pandemic. Allergy testing could reduce anxiety towards COVID-19 vaccination and thereby may increase vaccination rate, however, its effectiveness remains unclear.

METHODS

One hundred and thirty prospective real-life patients in need of but not daring to get vaccinated asked for allergy workup for COVID-19 vaccine hypersensitivity in 2021/2022. Characterization of patients, identification of anxieties, decrease of patient's anxiety levels, overall vaccination rate and adverse reactions after vaccination were assessed.

RESULTS

Tested patients were characterized by being female (91.5%) and having a high rate of previous allergies (e.g. to food 55.4%, drugs 54.6%, or previous vaccinations 50%) and dermatological disease (29.2%) but not always had medical contraindications for COVID-19 vaccination. Sixty one patients (49.6%) were highly concerned (4-6, Likert scale 0-6) about vaccination and 47 (37.6%) expressed resolving thoughts about vaccinaion anaphylaxis (3-6, Likert scale 0-6). However only 35 patients (28.5%) were scared of getting COVID-19 within 2 months (4-6, Likert scale 0-6) and only 11 (9%) patients had high expectations of getting COVID-19 (4-6, Likert scale 0-6). Allergy testing significantly (p < 0.01 to p < 0.05 respectively) reduced the median anxiety of allergic symptoms following vaccination: dyspnoea (4.2-3.1), to faint (3.7-2.7), long-term consequences (3.6-2.2), pruritus (3.4-2.6), skin rash (3.3-2.6) and death (3.2-2.6). After allergy testing, most patients (108/122, 88.5%) let themselves be vaccinated within 60 days. Revaccinated patients with previous symptoms experienced a reduction of symptoms (p < 0.05) upon revaccination.

CONCLUSIONS

Patients not daring to get vaccinated have more anxiety towards vaccination than to acquire COVID-19. For those, allergy testing excludes vaccine allergy, and is a tool to increase vaccination willingness and thereby helps to combat vaccination hesitancy.

Allergic Reactions to Vaccines in Children: From Constituents to Specific Vaccines

Vaccination is an essential public health measure that helps to reduce the burden of infectious diseases in children. Although vaccines have an excellent safety record and the association of severe allergic reactions is rare, public concerns about vaccine safety can lead to incomplete vaccination coverage in children with or without allergies. Therefore, it is important to understand the mechanisms and implications of allergic reactions to vaccines and define strategies to manage them to provide the safest care for vaccine recipients. In this review, we provide an overview on the types of allergic reactions that can occur after vaccination, including those caused by various vaccine constituents. We also discuss the mechanisms underlying these allergic reactions and the recommended diagnosis and management strategies for children with a history of suspected allergic reactions to vaccines. An improved understanding of allergic reactions to vaccines can aid in the enhancement of the safety and effectiveness of vaccination.

Self-Reported Allergic Adverse Events Following Inactivated SARS-CoV-2 Vaccine (TURKOVAC™) among General and High-Risk Population

TURKOVAC™ is a whole-virion inactivated COVID-19 vaccine which was developed and granted emergency use and conditional marketing authorization in December 2021 in Türkiye. The objective of this study is to assess the distribution and the severity of allergic adverse events following the administration of the vaccine as the primary or the booster dose in 15 provinces in Türkiye. In this cohort study, between February and May 2022, in the selected 15 provinces having an adequate number of health care personnel in the community health centers to conduct the study, 32,300 people having the first, the second, or the booster dose of the vaccine were invited to the survey. A total of 29,584 people voluntarily agreed to participate to the survey and were given a structured questionnaire after a minimum of 10 days following the vaccination. In our study, only 0.5% of the participants (142 persons) reported to experience any allergic reaction, and 12 of them (8.5%) reported to be given medical treatment in a health center. Male predominance (55.6%) was observed among participants reported to experience any allergic reaction. No hospitalization was recorded. Of the participants, 4.4% (1315 people) reported to have a history of allergy. The most reported allergens were drugs. Among the participants without a known history of allergy (n = 28,269), 0.4% of them (110 people) reported to experience an allergic reaction following the vaccination, and 5.4% of the allergic reactions (six people) were reported to be treated in a health center. The percentage of the participants given any medical treatment among the participants without a known history of allergy is 0.02%. No immediate or anaphylactic reaction was reported. Among the participants with a known history of allergy (n = 1315), 32 people (2.4% of them) reported to experience an allergic reaction following the vaccination, and 18.7% of the allergic reactions (six people) were reported to be prescribed a medical treatment. The percentage of the participants given any medical treatment among the participants with a known history of allergy is 0.4%. A known history of allergy increased the risk of having an allergic experience by approximately six times following vaccination. As a whole-virion inactivated SARS-CoV-2 vaccine, the TURKOVAC™ vaccine, with a low allergic reaction-related adverse event profile, can be an alternative to other COVID-19 vaccines.

Histopathological Patterns of Cutaneous Adverse Reaction to Anti-SARS-CoV-2 Vaccines: The Integrative Role of Skin Biopsy

The advent of vaccines represented a milestone to allow the slowing down and then containing of the exponential increase in ongoing infections and deaths of COVID-19. Since the first months of the vaccination campaign in various continents, there has been a certain number of reports of adverse events, including skin reactions. We conducted a systematic review, searching on PubMed, Web of Science, Scopus, and Cochrane Library for the words: COVID vaccine, dermatopathology, skin, eruptions, rash, cutaneous, BNT162b2 (Pfizer-BioNTech), ChAdOX1 (AstraZeneca), and mRNA-1273 (Moderna). A total of 28 records were initially identified in the literature search of which two were duplicates. After screening for eligibility and inclusion criteria, 18 publications were ultimately included. Various clinical cutaneous manifestations and histopathological patterns following vaccination have been described in literature. The most frequent clinical-pathological presentations were erythematous maculo-papular eruptions in different way of distribution with histopathological pictures mostly represented by interface changes and mixed peri-vascular and peri-adnexal cell infiltrate. Other presentations included new onset of pemphigoid bullous disease (n = 15), delayed T-cell-mediated hypersensitivity reaction (injection site reactions) (n = 10), purpuric skin rash (n = 13), mostly localized on the legs bilaterally and symmetrically with histological pictures characterized by extravasation of erythrocytes in the superficial and middle dermis, and other types of reactions. New studies with large case series and further literature reviews are needed to improve the clinical management of patients and optimize the timeline for carrying out histological biopsy for confirmatory, supportive, and differential diagnosis purposes.

The conundrum of COVID-19 mRNA vaccine-induced anaphylaxis

Novel messenger RNA (mRNA) vaccines have proven to be effective tools against coronavirus disease 2019, and they have changed the course of the pandemic. However, early reports of mRNA vaccine-induced anaphylaxis resulted in public alarm, contributing toward vaccine hesitancy. Although initial reports were concerning for an unusually high rate of anaphylaxis to the mRNA vaccines, the true incidence is likely comparable with other vaccines. These reactions occurred predominantly in young to middle-aged females, and many had a history of allergies. Although initially thought to be triggered by polyethylene glycol (PEG), lack of reproducibility of these reactions with subsequent dosing and absent PEG sensitization point away from an IgE-mediated PEG allergy in most. PEG skin testing has poor posttest probability and should be reserved for evaluating non-vaccine-related PEG allergy without influencing decisions for subsequent mRNA vaccination. Immunization stress-related response can closely mimic vaccine-induced anaphylaxis and warrants consideration as a potential etiology. Current evidence suggests that many individuals who developed anaphylaxis to the first dose of an mRNA vaccine can likely receive a subsequent dose after careful evaluation. The need to understand these reactions mechanistically remains critical because the mRNA platform is rapidly finding its way into other vaccinations and therapeutics.