1
|
Greenhawt M, Dribin TE, Abrams EM, Shaker M, Chu DK, Golden DBK, Akin C, Anagnostou A, ALMuhizi F, Alqurashi W, Arkwright P, Baldwin JL, Banerji A, Bégin P, Ben-Shoshan M, Bernstein J, Bingemann TA, Bindslev-Jensen C, Blumenthal K, Byrne A, Cahill J, Cameron S, Campbell D, Campbell R, Cavender M, Chan ES, Chinthrajah S, Comberiati P, Eastman JJ, Ellis AK, Fleischer DM, Fox A, Frischmeyer-Guerrerio PA, Gagnon R, Garvey LH, Grayson MH, Isabwe GAC, Hartog N, Hendron D, Horner CC, Hourihane JO, Iglesia E, Kan M, Kaplan B, Katelaris CH, Kim H, Kelso JM, Khan DA, Lang D, Ledford D, Levin M, Lieberman JA, Loh R, Mack DP, Mazer B, Mody K, Mosnaim G, Munblit D, Mustafa SS, Nanda A, Nathan R, Oppenheimer J, Otani IM, Park M, Pawankar R, Perrett KP, Peter J, Phillips EJ, Picard M, Pitlick M, Ramsey A, Rasmussen TH, Rathkopf MM, Reddy H, Robertson K, Rodriguez Del Rio P, Sample S, Sheshadri A, Sheik J, Sindher SB, Spergel JM, Stone CA, Stukus D, Tang MLK, Tracy JM, Turner PJ, Vander Leek TK, Wallace DV, Wang J, Wasserman S, Weldon D, Wolfson AR, Worm M, Yacoub MR. Updated guidance regarding the risk of allergic reactions to COVID-19 vaccines and recommended evaluation and management: A GRADE assessment and international consensus approach. J Allergy Clin Immunol 2023; 152:309-325. [PMID: 37295474 PMCID: PMC10247143 DOI: 10.1016/j.jaci.2023.05.019] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 05/08/2023] [Accepted: 05/11/2023] [Indexed: 06/12/2023]
Abstract
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.
Collapse
Affiliation(s)
- Matthew Greenhawt
- Section of Allergy and Clinical Immunology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colo.
| | - Timothy E Dribin
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Elissa M Abrams
- Department of Pediatrics and Child Health, Section of Allergy and Immunology, The University of Manitoba, Winnipeg, Canada
| | - Marcus Shaker
- Dartmouth-Hitchcock Medical Center, Section of Allergy and Immunology, Lebanon, NH; Dartmouth Geisel School of Medicine, Hanover, NH
| | - Derek K Chu
- Faculty of Medicine, and the Department of McMaster University, Hamilton, Canada; Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada; The Research Institute of St. Joe's Hamilton, Hamilton, Canada; Evidence in Allergy Group, McMaster University Medical Centre, Hamilton, Canada
| | - David B K Golden
- Division of Allergy and Clinical Immunology, Johns Hopkins University School of Medicine, Baltimore, Bethesda
| | - Cem Akin
- Division of Allergy and Clinical Immunology, Department of Internal Medicine, University of Michigan School, Ann Arbor, Mich
| | - Akterini Anagnostou
- Section of Immunology, Allergy, and Retrovirology, Department of Pediatrics, Baylor College of Medicine, Houston, Tex; Section of Immunology, Allergy and Retrovirology, Department of Pediatrics, Texas Children's Hospital, Houston, Tex
| | - Faisal ALMuhizi
- Division of Allergy and Clinical Immunology, Department of Internal Medicine, Security Forces Hospital Program, Riyadh, Arabia
| | - Waleed Alqurashi
- Department of Pediatrics and Emergency Medicine, University of Ottawa, Ottawa, Canada
| | - Peter Arkwright
- Lydia Becker Institute of Immunology and Inflammation, University of Manchester, Manchester, United Kingdom
| | - James L Baldwin
- Division of Allergy and Clinical Immunology, Department of Internal Medicine, University of Michigan School, Ann Arbor, Mich
| | - Aleena Banerji
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
| | - Philippe Bégin
- Centre Hospital Universitaire Sainte-Justine, Montreal, Canada
| | - Moshe Ben-Shoshan
- Division of Allergy, Immunology, and Dermatology, Department of Pediatrics, McGill University Health Center-Montreal Children's Hospital, Montreal, Canada
| | - Jonathan Bernstein
- Division of Immunology, Department of Internal Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Theresa A Bingemann
- Division of Allergy, Immunology, and Rheumatology, University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - Carsten Bindslev-Jensen
- Department of Dermatology and Allergy Center, Odense Research Centre for Anaphylaxis, Odense, Denmark
| | - Kim Blumenthal
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
| | - Aideen Byrne
- Department of Paediatrics, School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - Julia Cahill
- University of Alberta, Faculty of Medicine, Calgary, Canada
| | - Scott Cameron
- Allergy Victoria, Victoria, British Columbia, Canada
| | | | - Ronna Campbell
- Department of Emergency Medicine, Mayo Clinic, Rochester
| | | | - Edmond S Chan
- Division of Allergy and Immunology, BC Children's Hospital, The University of British Columbia, Vancouver, Canada
| | - Sharon Chinthrajah
- Division of Pulmonary, Allergy and Critical Care, Department of Medicine, Stanford University School of Medicine, Palo Alto, Calif; Division of Allergy, Immunology, and Rheumatology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, Calif; Sean N. Parker Center for Allergy and Asthma Research, Stanford University School of Medicine, Palo Alto, Calif
| | - Pasquale Comberiati
- Department of Clinical and Experimental Medicine, Section of Pediatrics, University of Pisa, Pisa, Italy
| | - Jacqueline J Eastman
- Corewell Health Allergy and Immunology, Grand Rapids, Mich; Michigan State University College of Human Medicine, Grand Rapids, Mich
| | - Anne K Ellis
- Division of Allergy and Immunology, Department of Medicine, Queen's University, Kingston, Canada
| | - David M Fleischer
- Section of Allergy and Clinical Immunology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colo
| | - Adam Fox
- Guys's and St Tomas's Hospital National Health Service Foundation Trust, London, Mass
| | - Pamela A Frischmeyer-Guerrerio
- Laboratory of Allergic Diseases, Food Allergy Research Section, National Institutes of Allergy and Infectious Diseases, the National Institutes of Health, Bethesda, Md
| | - Remi Gagnon
- Clinique Spécialisée en Allergie de la Capitale, Québec, Canada
| | - Lene H Garvey
- Allergy Clinic, Department of Dermatology and Allergy, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Mitchell H Grayson
- Division of Allergy and Immunology, Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, Ohio
| | - Ghislaine Annie Clarisse Isabwe
- Division of Allergy, Immunology, and Dermatology, Department of Pediatrics, McGill University Health Center-Montreal Children's Hospital, Montreal, Canada
| | - Nicholas Hartog
- Corewell Health Allergy and Immunology, Grand Rapids, Mich; Michigan State University College of Human Medicine, Grand Rapids, Mich
| | - David Hendron
- Access Health Care Physicians LLC, New Port Richey, Fla
| | - Caroline C Horner
- Division of Allergy and Pulmonary Medicine, Department of Pediatrics, Washington University School of Medicine, St Louis, Mo
| | | | - Edward Iglesia
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn
| | | | - Blanka Kaplan
- Division of Allergy and Immunology, Northwell Health, New York, NY
| | | | - Harold Kim
- Faculty of Medicine, and the Department of McMaster University, Hamilton, Canada; Division of Clinical Immunology and Allergy, Department of Medicine, Western University, St Joseph's Health Care, London (Canada), Mass
| | - John M Kelso
- Division of Allergy, Asthma, and Immunology, Scripps Clinic, San Diego, Calif
| | - David A Khan
- Division of Allergy and Immunology, Department of Medicine, University of Texas Southwestern Medical Center, Dallas, Tex
| | - David Lang
- Department of Allergy and Clinical Immunology, Respiratory Institute, Cleveland Clinic, Cleveland, Ohio
| | - Dennis Ledford
- Division of Allergy and Immunology, Department of Medicine, University of South Florida Morsani College of Medicine, Tampa, Fla
| | - Michael Levin
- Division of Paediatric Allergology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Jay A Lieberman
- Division of Allergy and Immunology, The University of Tennessee, Memphis, Tenn
| | - Richard Loh
- Immunology Department, Perth Children's Hospital, Perth, Australia
| | - Douglas P Mack
- Department of Pediatrics, McMaster University, Hamilton, Canada; Halton Pediatric Allergy, Burlington, Canada
| | - Bruce Mazer
- Division of Allergy, Immunology, and Dermatology, Department of Pediatrics, McGill University Health Center-Montreal Children's Hospital, Montreal, Canada
| | - Ketan Mody
- Elite Sports Medicine Institute Ltd, Westmont, Ill
| | - Gisele Mosnaim
- Division of Pulmonary, Allergy and Critical Care, Department of Medicine, NorthShore University Health System, Evanston, Ill
| | - Daniel Munblit
- Inflammation, Repair and Development Section, National Heart and Lung Institute, Faculty of Medicine, Imperial College London, London, Mass
| | - S Shahzad Mustafa
- Rochester Regional Health, University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - Anil Nanda
- Division of Allergy and Immunology, Department of Medicine, University of Texas Southwestern Medical Center, Dallas, Tex; Asthma and Allergy Center, Lewisville and Flower Mound, Dallas, Tex
| | | | - John Oppenheimer
- University of Medicine and Dentistry of New Jersey, Rutgers University School of Medicine, New Brunswick, NJ
| | - Iris M Otani
- Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, University of California San Francisco, San Francisco, Calif
| | - Miguel Park
- Division of Allergic Diseases, Mayo Clinic, Rochester
| | - Ruby Pawankar
- Department of Pediatrics, Nippon Medical School, Tokyo, Japan
| | - Kirsten P Perrett
- Division of Pulmonary, Allergy and Critical Care, Department of Medicine, NorthShore University Health System, Evanston, Ill; Population Allergy Group and the Centre for Food and Allergy Research, Murdoch Children's Research Institute, University of Melbourne, University of Melbourne, Royal Children's Hospital, Parkville, Australia; Department of Paediatrics, University of Melbourne, Parkville, Australia
| | - Jonny Peter
- Division of Allergy and Clinical Immunology, Department of Medicine, University of Cape Town and the Allergy and Immunology Unit, University of Cape Town Lung Institute, Cape Town
| | - Elizabeth J Phillips
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn; Center for Drug Safety and Immunology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn
| | - Matthieu Picard
- Hôspital Maisonneuve-Rosemont, Université de Montréal, Montreal, Canada
| | | | - Allison Ramsey
- Rochester Regional Health, University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - Trine Holm Rasmussen
- Department of Dermatology and Allergy Center, Odense Research Centre for Anaphylaxis, Odense, Denmark
| | | | - Hari Reddy
- Allergy, Asthma and Immunology Center of Alaska, Anchorage, Alaska; Department of Pediatrics, University of Washington School of Medicine, Seattle, Wash
| | - Kara Robertson
- Division of Clinical Immunology and Allergy, St Joseph's Health Care, London (Canada), Mass; Schulich School of Medicine and Dentistry, Western University, St Joseph's Health Care, London (Canada), Mass
| | | | | | - Ajay Sheshadri
- Department of Pulmonary Medicine, Division of Internal Medicine, The University of Texas MD Anderson Cancer Center, Houston, Tex
| | - Javed Sheik
- Kaiser Permanente Los Angeles Medical Center, Los Angeles, Calif
| | - Sayantani B Sindher
- Division of Pulmonary, Allergy and Critical Care, Department of Medicine, Stanford University School of Medicine, Palo Alto, Calif; Division of Allergy, Immunology, and Rheumatology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, Calif; Sean N. Parker Center for Allergy and Asthma Research, Stanford University School of Medicine, Palo Alto, Calif
| | - Jonathan M Spergel
- Division of Allergy and Immunology, Children's Hospital of Philadelphia, Philadelphia, Pa; Department of Pediatrics, Perelman School of Medicine at University of Pennsylvania, Philadelphia, Pa
| | - Cosby A Stone
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn
| | - David Stukus
- Division of Allergy and Immunology, Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, Ohio
| | - Mimi L K Tang
- Department of Allergy Immunology, Murdoch Children's Research Institute, Melbourne, Parkville, Australia; Department of Allergy and Immunology, Royal Children's Hospital, Parkville, Australia; Department of Paediatrics, University of Melbourne, Parkville, Australia
| | - James M Tracy
- Allergy, Asthma, and Immunology Associates PC, Omaha, Neb; Department of Pediatrics, University of Nebraska School of Medicine, Omaha, Neb
| | - Paul J Turner
- Imperial College Healthcare National Health Service Trust, London, Mass; Royal Brompton and Harefield National Health Service Foundation Trust, London, Mass
| | - Timothy K Vander Leek
- Pediatric Allergy and Immunology, Department of Pediatrics, Stollery Children's Hospital, University of Alberta, Edmonton, Canada
| | - Dana V Wallace
- Nova Southeastern University College of Allopathic Medicine, Fort Lauderdale, Fla
| | - Julie Wang
- Division of Pediatric Allergy and Immunology, Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY; Jaffe Food Allergy Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Susan Wasserman
- Division of Clinical Immunology and Allergy, Department of Medicine, McMaster University, Hamilton, Canada
| | - David Weldon
- Baylor Scott and White Clinic, College Station, Tex
| | - Anna R Wolfson
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
| | - Margitta Worm
- Division of Allergology and Immunology, Department of Dermatology, Venereology and Allergology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Mona-Rita Yacoub
- Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele Hospital, Unit of Immunology, Rheumatology, Allergy and Rare Diseases, Segrate, Milan, Italy
| |
Collapse
|
2
|
Zhou ZH, Cortese MM, Fang JL, Wood R, Hummell DS, Risma KA, Norton AE, KuKuruga M, Kirshner S, Rabin RL, Agarabi C, Staat MA, Halasa N, Ware RE, Stahl A, McMahon M, Browning P, Maniatis P, Bolcen S, Edwards KM, Su JR, Dharmarajan S, Forshee R, Broder KR, Anderson S, Kozlowski S. Evaluation of association of anti-PEG antibodies with anaphylaxis after mRNA COVID-19 vaccination. Vaccine 2023:S0264-410X(23)00568-6. [PMID: 37244808 DOI: 10.1016/j.vaccine.2023.05.029] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 05/10/2023] [Accepted: 05/11/2023] [Indexed: 05/29/2023]
Abstract
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.
Collapse
Affiliation(s)
- Zhao-Hua Zhou
- Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, MD, USA
| | - Margaret M Cortese
- Immunization Safety Office, Division of Healthcare Quality and Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Jia-Long Fang
- National Center for Toxicological Research, FDA, Jefferson, AR, USA
| | - Robert Wood
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Donna S Hummell
- Division of Pediatric Allergy, Immunology, and Pulmonary Medicine, Monroe Carell Jr. Children's Hospital at Vanderbilt, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Kimberly A Risma
- Division of Allergy Immunology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Allison E Norton
- Division of Pediatric Allergy, Immunology, and Pulmonary Medicine, Monroe Carell Jr. Children's Hospital at Vanderbilt, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Mark KuKuruga
- Center for Biologics Evaluation and Research, Food and Drug Administration, USA
| | - Susan Kirshner
- Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, MD, USA
| | - Ronald L Rabin
- Center for Biologics Evaluation and Research, Food and Drug Administration, USA
| | - Cyrus Agarabi
- Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, MD, USA
| | - Mary A Staat
- Division of Infectious Disease, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Natasha Halasa
- Division of Infectious Diseases, Department of Pediatrics, Monroe Carell Jr. Children's Hospital at Vanderbilt, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Russell E Ware
- Division of Hematology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Anna Stahl
- Division of Infectious Diseases, Department of Pediatrics, Monroe Carell Jr. Children's Hospital at Vanderbilt, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Maureen McMahon
- Division of Infectious Disease, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Peter Browning
- Microbial Pathogenesis and Immune Response Laboratory, Division of Bacterial Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Panagiotis Maniatis
- Microbial Pathogenesis and Immune Response Laboratory, Division of Bacterial Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Shanna Bolcen
- Microbial Pathogenesis and Immune Response Laboratory, Division of Bacterial Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Kathryn M Edwards
- Division of Infectious Diseases, Department of Pediatrics, Monroe Carell Jr. Children's Hospital at Vanderbilt, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - John R Su
- Immunization Safety Office, Division of Healthcare Quality and Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Sai Dharmarajan
- Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, MD, USA
| | - Richard Forshee
- Center for Biologics Evaluation and Research, Food and Drug Administration, USA
| | - Karen R Broder
- Immunization Safety Office, Division of Healthcare Quality and Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Steven Anderson
- Center for Biologics Evaluation and Research, Food and Drug Administration, USA
| | - Steven Kozlowski
- Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, MD, USA.
| |
Collapse
|
3
|
Messina MR, Crisciotti C, Pellegrini L, Nappi E, Racca F, Costanzo G, Del Moro L, Ferri S, Puggioni F, Canonica GW, Heffler E, Paoletti G. Desensitization Protocols for Anti-SARS-CoV-2 Vaccines in Patients with High Risk of Allergic Reactions. Vaccines (Basel) 2023; 11:vaccines11050910. [PMID: 37243013 DOI: 10.3390/vaccines11050910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 04/20/2023] [Accepted: 04/26/2023] [Indexed: 05/28/2023] Open
Abstract
Vaccines for SAR-CoV-2 are the most effective preventive treatment able to reduce the risk of contracting the infection and experiencing worse outcomes whenever the infection is contracted. Despite their rarity, hypersensitivity reactions to the anti-SARS-CoV-2 vaccine have been described and could become the reason not to complete the vaccination. Desensitization protocols for other vaccines have been described and validated, while the use of this approach for anti-SARS-CoV-2 vaccines is still anecdotal. We herein describe our experience with 30 patients with previous allergic reactions to anti-SARS-CoV-2 vaccines or to any of their excipients, proving that they are effective and safe; only two patients experienced hypersensitivity reaction symptoms during the desensitization procedure. Moreover, in this article, we propose desensitization protocols for the most common anti-SARS-CoV-2 vaccines.
Collapse
Affiliation(s)
- Maria Rita Messina
- Personalized Medicine, Asthma and Allergy, IRCCS Humanitas Research Hospital, Rozzano, 20089 Milan, Italy
| | - Carlotta Crisciotti
- Personalized Medicine, Asthma and Allergy, IRCCS Humanitas Research Hospital, Rozzano, 20089 Milan, Italy
| | - Laura Pellegrini
- Personalized Medicine, Asthma and Allergy, IRCCS Humanitas Research Hospital, Rozzano, 20089 Milan, Italy
| | - Emanuele Nappi
- Personalized Medicine, Asthma and Allergy, IRCCS Humanitas Research Hospital, Rozzano, 20089 Milan, Italy
| | - Francesca Racca
- Personalized Medicine, Asthma and Allergy, IRCCS Humanitas Research Hospital, Rozzano, 20089 Milan, Italy
| | - Giovanni Costanzo
- Personalized Medicine, Asthma and Allergy, IRCCS Humanitas Research Hospital, Rozzano, 20089 Milan, Italy
| | - Lorenzo Del Moro
- Personalized Medicine, Asthma and Allergy, IRCCS Humanitas Research Hospital, Rozzano, 20089 Milan, Italy
- Department of Clinical and Experimental Medicine, University of Florence, 50139 Florence, Italy
| | - Sebastian Ferri
- Personalized Medicine, Asthma and Allergy, IRCCS Humanitas Research Hospital, Rozzano, 20089 Milan, Italy
| | - Francesca Puggioni
- Personalized Medicine, Asthma and Allergy, IRCCS Humanitas Research Hospital, Rozzano, 20089 Milan, Italy
| | - Giorgio Walter Canonica
- Personalized Medicine, Asthma and Allergy, IRCCS Humanitas Research Hospital, Rozzano, 20089 Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, 20090 Milan, Italy
| | - Enrico Heffler
- Personalized Medicine, Asthma and Allergy, IRCCS Humanitas Research Hospital, Rozzano, 20089 Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, 20090 Milan, Italy
| | - Giovanni Paoletti
- Personalized Medicine, Asthma and Allergy, IRCCS Humanitas Research Hospital, Rozzano, 20089 Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, 20090 Milan, Italy
| |
Collapse
|
4
|
Jaggers J, Wolfson AR. mRNA COVID-19 Vaccine Anaphylaxis: Epidemiology, Risk Factors, and Evaluation. Curr Allergy Asthma Rep 2023; 23:195-200. [PMID: 36689047 PMCID: PMC9869308 DOI: 10.1007/s11882-023-01065-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/07/2022] [Indexed: 01/24/2023]
Abstract
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.
Collapse
Affiliation(s)
- Jordon Jaggers
- Harvard Medical School, Boston, MA, USA.,Department of Internal Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Anna R Wolfson
- Harvard Medical School, Boston, MA, USA. .,Department of Internal Medicine, Massachusetts General Hospital, Boston, MA, USA. .,Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, 55 Fruit Street, Yawkey 4B, Boston, MA, 02411, USA.
| |
Collapse
|
5
|
Khalid MB, Frischmeyer-Guerrerio PA. The conundrum of COVID-19 mRNA vaccine-induced anaphylaxis. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. GLOBAL 2023; 2:1-13. [PMID: 36532656 PMCID: PMC9746073 DOI: 10.1016/j.jacig.2022.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Revised: 10/19/2022] [Accepted: 10/26/2022] [Indexed: 12/14/2022]
Abstract
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.
Collapse
Key Words
- AE, Adverse event
- BAT, Basophil activation test
- CARPA, Complement activation–related pseudoallergy
- COVID-19
- COVID-19, Coronavirus disease 2019
- ISRR
- ISRR, Immunization stress–related response
- LNP, Lipid nanoparticle
- PAF, Platelet-activating factor
- PEG
- PEG, Polyethylene glycol
- SARS-CoV-2, Severe acute respiratory syndrome coronavirus 2
- VAERS, Vaccine adverse event reporting system
- allergic reaction
- allergy
- anaphylaxis
- immunization stress–related response
- mRNA
- mRNA, Messenger RNA
- polyethylene glycol
- vaccine
Collapse
Affiliation(s)
| | - Pamela A. Frischmeyer-Guerrerio
- Corresponding author: Pamela A. Frischmeyer-Guerrerio, MD, PhD, Laboratory of Allergic Diseases, Food Allergy Research Section, National Institute of Allergy and Infectious Diseases, National Institutes of Health, MSC 1881, 10 Center Dr, Bethesda, MD 20892
| |
Collapse
|
6
|
Greenhawt M, Shaker M, Golden DBK, Abrams EM, Blumenthal KG, Wolfson AR, Stone CA, Krantz MS, Chu DK, Dwamena BA. Diagnostic accuracy of vaccine and vaccine excipient testing in the setting of allergic reactions to COVID-19 vaccines: A systematic review and meta-analysis. Allergy 2023; 78:71-83. [PMID: 36321821 PMCID: PMC9878056 DOI: 10.1111/all.15571] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 09/14/2022] [Accepted: 10/04/2022] [Indexed: 11/05/2022]
Abstract
For persons with immediate allergic reactions to mRNA COVID-19 vaccines, skin testing (ST) to the vaccine/excipients (polyethylene glycol[PEG] and polysorbate 80 [PS]) has been recommended, but has unknown accuracy. To assess vaccine/excipient ST accuracy in predicting all-severity immediate allergic reactions upon re-vaccination, systematic review was performed searching Medline, EMBASE, Web of Science, and the WHO global coronavirus database (inception-Oct 4, 2021) for studies addressing immediate (≤4 h post-vaccination) all-severity allergic reactions to 2nd mRNA COVID-19 vaccination in persons with 1st dose immediate allergic reactions. Cases evaluating delayed reactions, change of vaccine platform, or revaccination without vaccine/excipient ST were excluded. Meta-analysis of diagnostic testing accuracy was performed using Bayesian methods. The GRADE approach evaluated certainty of the evidence, and QUADAS-2 assessed risk of bias. Among 20 studies of mRNA COVID-19 first dose vaccine reactions, 317 individuals underwent 578 ST to any one or combination of vaccine, PEG, or PS, and were re-vaccinated with the same vaccine. Test sensitivity for either mRNA vaccine was 0.2 (95%CrI 0.01-0.52) and specificity 0.97 (95%CrI 0.9-1). PEG test sensitivity was 0.02 (95%CrI 0.00-0.07) and specificity 0.99 (95%CrI 0.96-1). PS test sensitivity was 0.03 (95%CrI 0.00-0.0.11) and specificity 0.97 (95%CrI 0.91-1). Combined for use of any of the 3 testing agents, sensitivity was 0.03 (95%CrI 0.00-0.08) and specificity was 0.98 (95%CrI 0.95-1.00). Certainty of evidence was moderate. ST has low sensitivity but high specificity in predicting all-severity repeat immediate allergic reactions to the same agent, among persons with 1st dose immediate allergic reactions to mRNA COVID-19 vaccines. mRNA COVID-19 vaccine or excipient ST has limited risk assessment utility.
Collapse
Affiliation(s)
- Matthew Greenhawt
- Section of Allergy and Clinical Immunology, Children's Hospital ColoradoUniversity of Colorado School of MedicineAuroraColoradoUSA
| | - Marcus Shaker
- Dartmouth‐Hitchcock Medical Center, Section of Allergy and ImmunologyLebanonNew HampshireUSA,Dartmouth Geisel School of MedicineHanoverNew HampshireUSA
| | - David B. K. Golden
- Division of Allergy and Clinical ImmunologyJohns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Elissa M. Abrams
- Department of Pediatrics and Child Health, Section of Allergy and ImmunologyThe University of ManitobaWinnipegManitobaCanada
| | - Kimberly G. Blumenthal
- Division of Rheumatology, Allergy, and ImmunologyDepartment of Medicine, Massachusetts General HospitalHarvard Medical SchoolBostonMassachusettsUSA
| | - Anna R. Wolfson
- Division of Rheumatology, Allergy, and ImmunologyDepartment of Medicine, Massachusetts General HospitalHarvard Medical SchoolBostonMassachusettsUSA
| | - Cosby A. Stone
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of MedicineVanderbilt University School of MedicineNashvilleTennesseeUSA
| | - Matthew S. Krantz
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of MedicineVanderbilt University School of MedicineNashvilleTennesseeUSA
| | - Derek K. Chu
- Department of MedicineMcMaster UniversityHamiltonOntarioCanada,Department of Health Research Methods, Evidence & ImpactMcMaster UniversityHamiltonOntarioCanada,The Research Institute of St. Joe's HamiltonHamiltonOntarioCanada,Evidence in Allergy GroupHamiltonOntarioCanada
| | - Ben A. Dwamena
- Division of Nuclear Medicine, Department of Radiology, Michigan MedicineUniversity of Michigan Medical SchoolAnn ArborMichiganUSA
| |
Collapse
|
7
|
Petrelli F, Giannini D, Pucci C, Del Corso I, Rocchi V, Dolcher MP, Pieve G, Pratesi F, Migliorini P, Puxeddu I. Allergy Workup in the Diagnosis of COVID-19 Vaccines-Induced Hypersensitivity Reactions and Its Impact on Vaccination. Int Arch Allergy Immunol 2022; 184:54-62. [PMID: 36265449 PMCID: PMC9747735 DOI: 10.1159/000526764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 08/17/2022] [Indexed: 01/06/2023] Open
Abstract
INTRODUCTION Immediate and delayed hypersensitivity reactions (HSR) to COVID-19 vaccines are rare adverse events that need to be prevented, diagnosed, and managed in order to guarantee adherence to the vaccination campaign. The aims of our study were to stratify the risk of HSR to COVID-19 vaccines and propose alternative strategies to complete the vaccination. METHODS 1,640 subjects were screened for vaccinal eligibility, according to national and international recommendations. Among them, we enrolled for allergy workup 152 subjects, 43 with HSR to COVID-19 vaccines and 109 at high risk of HSR to the first dose. In vivo skin tests with drugs and/or vaccines containing PEG/polysorbates were performed in all of them, using skin prick test and, when negative, intradermal tests. In a subgroup of patients resulted negative to the in vivo skin tests, the programmed dose of COVID-19 vaccine (Pfizer/BioNTech) was administered in graded doses regimen, and detection of neutralizing anti-spike antibodies was performed in these patients after 4 weeks from the vaccination, using the SPIA method. RESULTS Skin tests for PEG/polysorbates resulted positive in only 3% (5/152) of patients, including 2 with previous HSR to COVID-19 vaccines and 3 at high risk of HSR to the first dose. Among the 147 patients with negative skin tests, 97% (143/147) were eligible for vaccination and 87% (124/143) of them received safely the programmed COVID-19 vaccine dose. Administration of graded doses of Pfizer/BioNTech vaccine were well tolerated in 17 out of 18 patients evaluated; only 1 developed an HSR during the vaccination, less severe than the previous one, and all developed neutralizing anti-spike antibodies after 4 weeks with values comparable to those subjects who received the vaccine in unfractionated dose. CONCLUSION On the whole, the usefulness of the skin tests for PEG/polysorbates seems limited in the diagnosis of HSR to COVID-19 vaccines. Graded doses regimen (Pfizer/BioNTech) is a safe and effective alternative strategy to complete the vaccinal course.
Collapse
Affiliation(s)
- Fiorella Petrelli
- Immunoallergology Unit, Department of Clinical and Experimental Medicine, Pisa University, Pisa, Italy
| | - Daiana Giannini
- Immunoallergology Unit, Department of Clinical and Experimental Medicine, Pisa University, Pisa, Italy
| | - Celestino Pucci
- Immunoallergology Unit, Department of Clinical and Experimental Medicine, Pisa University, Pisa, Italy
| | - Isabella Del Corso
- Immunoallergology Unit, Department of Clinical and Experimental Medicine, Pisa University, Pisa, Italy
| | - Valeria Rocchi
- Immunoallergology Unit, Department of Clinical and Experimental Medicine, Pisa University, Pisa, Italy
| | - Maria Pia Dolcher
- Immunoallergology Unit, Department of Clinical and Experimental Medicine, Pisa University, Pisa, Italy
| | - Giulio Pieve
- UO Direzione Medica di Presidio, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Federico Pratesi
- Immunoallergology Unit, Department of Clinical and Experimental Medicine, Pisa University, Pisa, Italy
| | - Paola Migliorini
- Immunoallergology Unit, Department of Clinical and Experimental Medicine, Pisa University, Pisa, Italy
| | - Ilaria Puxeddu
- Immunoallergology Unit, Department of Clinical and Experimental Medicine, Pisa University, Pisa, Italy,*Ilaria Puxeddu,
| |
Collapse
|
8
|
Split dosing of coronavirus disease 2019 vaccines provides noninferior antibody responsiveness to conventional vaccine dosing. Ann Allergy Asthma Immunol 2022; 129:794-796. [PMID: 36084864 PMCID: PMC9448634 DOI: 10.1016/j.anai.2022.08.995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 07/28/2022] [Accepted: 08/21/2022] [Indexed: 11/21/2022]
|
9
|
Corey KB, Koo G, Phillips EJ. Adverse Events and Safety of SARS-CoV-2 Vaccines: What's New and What's Next. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2022; 10:2254-2266. [PMID: 35550878 PMCID: PMC9085443 DOI: 10.1016/j.jaip.2022.04.035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 04/26/2022] [Accepted: 04/27/2022] [Indexed: 12/29/2022]
Abstract
Just over 1 year following rollout of the first vaccines for coronavirus disease 2019, 572 million doses have been administered in the United States. Compared with the number of vaccines administered, adverse effects such as anaphylaxis have been rare, and seemingly, the more serious the effect, the rarer the occurrence. Despite these adverse effects, there are few, if any, true contraindications to coronavirus disease 2019 vaccination and most individuals recover without further sequelae. This review provides guidance for the allergist/immunologist regarding appropriate next steps based on patient's known allergy history or adverse reaction after receipt of coronavirus disease 2019 vaccine to assist in safe global immunization.
Collapse
Affiliation(s)
- Kristen B Corey
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn
| | - Grace Koo
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn
| | - Elizabeth J Phillips
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn; Institute for Immunology and Infectious Diseases, Murdoch University, Murdoch, WA, Australia.
| |
Collapse
|
10
|
De Luca JF, Awad A, Vogrin S, Douglas AP, Lutjen A, Gordon SF, Crawford NW, Barnes S, Trubiano JA. Safety of COVID-19 vaccine challenge in patients with immediate adverse reactions to prior doses: A multi-centre cohort study. Allergy 2022; 78:293-296. [PMID: 35924675 PMCID: PMC9539178 DOI: 10.1111/all.15467] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 07/23/2022] [Accepted: 08/02/2022] [Indexed: 12/30/2022]
Affiliation(s)
- Joseph F. De Luca
- Centre for Antibiotic Allergy and Research, Department of Infectious DiseasesAustin HealthHeidelbergVic.Australia,Department of MedicineUniversity of MelbourneMelbourneVic.Australia
| | - Andrew Awad
- Centre for Antibiotic Allergy and Research, Department of Infectious DiseasesAustin HealthHeidelbergVic.Australia
| | - Sara Vogrin
- Department of MedicineSt Vincent's Hospital, University of MelbourneFitzroyVic.Australia
| | - Abby P. Douglas
- Centre for Antibiotic Allergy and Research, Department of Infectious DiseasesAustin HealthHeidelbergVic.Australia
| | - Antje Lutjen
- Department of AllergyMonash HealthClaytonVic.Australia
| | - Sally F. Gordon
- Vaccine Safety and Evaluation, COVID‐19 Vaccination ProgramVictorian Department of HealthMelbourneVic.Australia
| | - Nigel W. Crawford
- SAEFVIC, Victorian Vaccine Safety ServiceMCRIParkvilleVic.Australia,Department of PaediatricsUniversity of MelbourneMelbourneVic.Australia
| | - Sara Barnes
- Department of AllergyMonash HealthClaytonVic.Australia
| | - Jason A. Trubiano
- Centre for Antibiotic Allergy and Research, Department of Infectious DiseasesAustin HealthHeidelbergVic.Australia,Department of MedicineUniversity of MelbourneMelbourneVic.Australia
| |
Collapse
|
11
|
Regula P, Rosenstreich D, Jerschow E, Ramesh M, Ferastraoaru D, Oh J, Aivazi DS, Aivazi JM, Hudes G. Safety and efficacy of graded dosing of Pfizer-BioNTech mRNA COVID-19 vaccine after an immediate hypersensitivity reaction to first dose. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. GLOBAL 2022; 1:175-177. [PMID: 36164368 PMCID: PMC9055417 DOI: 10.1016/j.jacig.2022.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 04/06/2022] [Accepted: 04/11/2022] [Indexed: 11/17/2022]
Abstract
Current guidelines do not recommend subsequent mRNA COVID-19 vaccination in patients who experience immediate allergic reactions to the first dose. Our findings indicate that graded dosing of this vaccine is safe, efficacious, and useful for treating these individuals with allergy.
Collapse
Affiliation(s)
- Prudhvi Regula
- Division of Allergy and Immunology, Department of Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY
| | - David Rosenstreich
- Division of Allergy and Immunology, Department of Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY
| | - Elina Jerschow
- Division of Allergy and Immunology, Department of Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY
| | - Manish Ramesh
- Division of Allergy and Immunology, Department of Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY
| | - Denisa Ferastraoaru
- Division of Allergy and Immunology, Department of Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY
| | - Jessica Oh
- Division of Allergy and Immunology, Department of Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY
| | - Daniella S Aivazi
- CUNY School of Medicine, the Sophie Davis School of Biomedical Education Program, New York, NY
| | - Jonathan M Aivazi
- the New York Institute of Technology College of Osteopathic Medicine, Glen Head, NY
| | - Golda Hudes
- Division of Allergy and Immunology, Department of Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY
| |
Collapse
|
12
|
Copaescu AM, Rosa Duque JS, Phillips EJ. What have we learned about the allergenicity and adverse reactions associated with the severe acute respiratory syndrome coronavirus 2 vaccines: One year later. Ann Allergy Asthma Immunol 2022; 129:40-51. [PMID: 35390476 PMCID: PMC8979618 DOI: 10.1016/j.anai.2022.03.030] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 03/24/2022] [Accepted: 03/25/2022] [Indexed: 12/20/2022]
Abstract
OBJECTIVE The coronavirus disease 2019 (COVID-19) pandemic caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has led to the most rapid response and scale-up in vaccine and therapeutic development in history. We highlight the history of these amazing achievements with a focus on the description of the classification and mechanisms of allergic reactions and adverse events relevant to the allergist and immunologist that have been associated with the SARS-CoV-2 vaccines. Finally, we offer a detailed management approach in the context of a possible allergic reaction. DATA SOURCES Using defined search strategy, we identified peer-reviewed articles within PubMed that were published between January 1, 2019, and December 4, 2021. STUDY SELECTIONS All recent articles on COVID-19 published in English were reviewed with focus on the immunogenicity and allergenicity of the current existing COVID-19 vaccines. RESULTS Following a detailed literature review, we discuss the evolution and development of the new vaccines for SARS-CoV-2. Furthermore, we provide evidence regarding the significance and mechanisms of allergic reactions associated with the vaccines and offer a management approach for those with an increased risk of presenting an allergic or other relevant vaccine reaction. CONCLUSION The international rollout of COVID-19 vaccination started with reports of immediate allergic reactions. Although we still need to understand the mechanisms of these reactions, we can be reassured that patients with underlying allergic disease will not need to avoid SARS-CoV-2 vaccination. In addition, the vast majority of those with a first-dose reaction will tolerate subsequent doses.
Collapse
Affiliation(s)
- Ana M Copaescu
- Division of Allergy and Clinical Immunology, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada; The Research Institute of the McGill University Health Centre, McGill University, Montreal, Quebec, Canada; Centre for Antibiotic Allergy and Research, Department of Infectious Diseases, Austin Health, Heidelberg, Victoria, Australia
| | - Jaime S Rosa Duque
- Li Ka Shing Faculty of Medicine, Department of Paediatrics and Adolescent Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Elizabeth Jane Phillips
- Center for Drug Safety and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee; Institute for Immunology & Infectious Diseases, Murdoch University, Murdoch, Western Australia, Australia.
| |
Collapse
|
13
|
Roth MS, Chantraine S, Morales Mateluna C, Hartmann K, Berger CT. Safe administration of subsequent mRNA COVID-19 vaccine doses following a possible allergic reaction to the first dose. J Eur Acad Dermatol Venereol 2022; 36:e880-e883. [PMID: 35771081 PMCID: PMC9350139 DOI: 10.1111/jdv.18387] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Michèle S Roth
- Division of Allergy, Department of Dermatology, University Hospital Basel and University of Basel, Basel, Switzerland.,Division of Allergy, University Children's Hospital of Basel, Basel, Switzerland
| | - Sibylla Chantraine
- Division of Allergy, Department of Dermatology, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Carlos Morales Mateluna
- Division of Allergy, Department of Dermatology, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Karin Hartmann
- Division of Allergy, Department of Dermatology, University Hospital Basel and University of Basel, Basel, Switzerland.,Department of Biomedicine, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Christoph T Berger
- Division of Allergy, Department of Dermatology, University Hospital Basel and University of Basel, Basel, Switzerland.,Department of Biomedicine, University Hospital Basel and University of Basel, Basel, Switzerland.,University Center for Immunology, University Hospital Basel, Basel, Switzerland
| |
Collapse
|
14
|
Pitlick MM, Gonzalez-Estrada A, Park MA. Graded coronavirus disease 2019 vaccine administration: A safe alternative to vaccine avoidance. Ann Allergy Asthma Immunol 2022; 128:731-733. [PMID: 35257875 PMCID: PMC8894737 DOI: 10.1016/j.anai.2022.02.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 02/18/2022] [Accepted: 02/25/2022] [Indexed: 01/31/2023]
Affiliation(s)
| | | | - Miguel A Park
- Division of Allergic Diseases, Mayo Clinic, Rochester, Minnesota
| |
Collapse
|
15
|
Outcomes of allergic-type reactions after messenger RNA coronavirus disease 2019 vaccination at 3 military medical centers. Ann Allergy Asthma Immunol 2022; 129:248-249. [PMID: 35598884 PMCID: PMC9119161 DOI: 10.1016/j.anai.2022.05.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 05/09/2022] [Accepted: 05/11/2022] [Indexed: 11/30/2022]
|
16
|
Van Meerbeke SW, Fajt ML, Marini RV, Domsic RT, Petrov AA. Antibody response to graded dosing of coronavirus disease 2019 messenger RNA vaccines after allergic reaction to first dose. Ann Allergy Asthma Immunol 2022; 129:373-374. [PMID: 35595005 PMCID: PMC9112645 DOI: 10.1016/j.anai.2022.05.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 05/08/2022] [Accepted: 05/09/2022] [Indexed: 12/26/2022]
Affiliation(s)
- Sara W Van Meerbeke
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Merritt L Fajt
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Rachel V Marini
- Department of Pharmacy, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Robyn T Domsic
- Division of Rheumatology and Clinical Immunology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Andrej A Petrov
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
| |
Collapse
|
17
|
Chu DK, Abrams EM, Golden DBK, Blumenthal KG, Wolfson AR, Stone CA, Krantz MS, Shaker M, Greenhawt M. Risk of Second Allergic Reaction to SARS-CoV-2 Vaccines: A Systematic Review and Meta-analysis. JAMA Intern Med 2022; 182:376-385. [PMID: 35188528 PMCID: PMC8861900 DOI: 10.1001/jamainternmed.2021.8515] [Citation(s) in RCA: 62] [Impact Index Per Article: 31.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 12/26/2021] [Indexed: 12/12/2022]
Abstract
IMPORTANCE Vaccination against SARS-CoV-2 is a highly effective strategy to prevent infection and severe COVID-19 outcomes. The best strategy for a second dose of vaccine among persons who had an immediate allergic reaction to their first SARS CoV-2 vaccination is unclear. OBJECTIVE To assess the risk of severe immediate allergic reactions (eg, anaphylaxis) to a second dose of SARS-CoV-2 mRNA vaccine among persons with immediate allergic reactions to their first vaccine dose. DATA SOURCES MEDLINE, Embase, Web of Science, and the World Health Organization Global Coronavirus database were searched from inception through October 4, 2021. STUDY SELECTION Included studies addressed immediate allergic reactions of any severity to a second SARS-CoV-2 vaccine dose in persons with a known or suspected immediate allergic reaction (<4 hours after vaccination) after their first SARS-CoV-2 vaccine dose. Studies describing a second vaccine dose among persons reporting delayed reactions (>4 hours after vaccination) were excluded. DATA EXTRACTION AND SYNTHESIS Paired reviewers independently selected studies, extracted data, and assessed risk of bias. Random-effects models were used for meta-analysis. The GRADE (Grading of Recommendation, Assessment, Development, and Evaluation) approach evaluated certainty of the evidence. MAIN OUTCOMES AND MEASURES Risk of severe immediate allergic reaction and repeated severe immediate allergic reactions with a second vaccine dose. Reaction severity was defined by the reporting investigator, using Brighton Collaboration Criteria, Ring and Messmer criteria, World Allergy Organization criteria, or National Institute of Allergy and Infectious Diseases criteria. RESULTS Among 22 studies of SARS-CoV-2 mRNA vaccines, 1366 individuals (87.8% women; mean age, 46.1 years) had immediate allergic reactions to their first vaccination. Analysis using the pooled random-effects model found that 6 patients developed severe immediate allergic reactions after their second vaccination (absolute risk, 0.16% [95% CI, 0.01%-2.94%]), 232 developed mild symptoms (13.65% [95% CI, 7.76%-22.9%]), and, conversely, 1360 tolerated the dose (99.84% [95% CI, 97.09%-99.99%]). Among 78 persons with severe immediate allergic reactions to their first SARS-CoV-2 mRNA vaccination, 4 people (4.94% [95% CI, 0.93%-22.28%]) had a second severe immediate reaction, and 15 had nonsevere symptoms (9.54% [95% CI, 2.18%-33.34%]). There were no deaths. Graded vaccine dosing, skin testing, and premedication as risk-stratification strategies did not alter the findings. Certainty of evidence was moderate for those with any allergic reaction to the first dose and low for those with severe allergic reactions to the first dose. CONCLUSIONS AND RELEVANCE In this systematic review and meta-analysis of case studies and case reports, the risk of immediate allergic reactions and severe immediate reactions or anaphylaxis associated with a second dose of an SARS-CoV-2 mRNA vaccine was low among persons who experienced an immediate allergic reaction to their first dose. These findings suggest that revaccination of individuals with an immediate allergic reaction to a first SARS-CoV-2 mRNA vaccine dose in a supervised setting equipped to manage severe allergic reactions can be safe.
Collapse
Affiliation(s)
- Derek K. Chu
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence & Impact, McMaster University, Hamilton, Ontario, Canada
- The Research Institute of St Joe’s Hamilton, Hamilton, Ontario, Canada
- Evidence in Allergy Group, Hamilton, Ontario, Canada
| | - Elissa M. Abrams
- Section of Allergy and Immunology, Department of Pediatrics and Child Health, The University of Manitoba, Winnipeg, Manitoba, Canada
| | - David B. K. Golden
- Division of Allergy and Clinical Immunology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Kimberly G. Blumenthal
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Anna R. Wolfson
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Cosby A. Stone
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Matthew S. Krantz
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Marcus Shaker
- Section of Allergy and Immunology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
- Dartmouth Geisel School of Medicine, Hanover, New Hampshire
| | - Matthew Greenhawt
- Food Challenge and Research Unit, Section of Allergy and Clinical Immunology, Children’s Hospital Colorado, University of Colorado School of Medicine, Aurora
| |
Collapse
|