Who Is Really at Risk for Anaphylaxis Due to COVID-19 Vaccine?

Association of behaviors and asthma control in a sample of Lebanese adolescents with asthma

BACKGROUND

The relationship between behavioral problems and asthma is bidirectional; while the presence of a chronic disease such as asthma might predispose the person to stress, anxiety, and other behavioral issues, behavioral problems might in turn cause uncontrolled asthma through nonadherence to asthma management strategies. In Lebanon, behavioral problems and uncontrolled asthma could be of significant concern for adolescents. Consequently, we found it necessary to evaluate association between behavioral problems and uncontrolled asthma in a sample of Lebanese adolescents.

METHODS

Data for this cross-sectional study were collected using the snowball sampling technique in July 2023. The questionnaire was developed with Google Forms and distributed to participants via social media platforms and messaging applications. The Asthma Control Test (ACT) was used to check for uncontrolled asthma, and the Youth Self-Report (YSR) scale was used to assess behavioral problems. It yields nine subscales (anxious-depressed, withdrawn-depressed, somatic complaints, social problems, thought problems, attention problems, rule-breaking behavior, aggressive behavior, and other problems) and a total score.

RESULTS

When taking each behavior score as an independent variable, older age was associated with lower ACT scores (more controlled asthma); F(15, 186) = 3.66, P = 0.014, and 95% Confidence Interval (CI) [-0.85, -0.10]. Living in a rural area, compared to urban was associated with higher ACT scores, P = 0.018, and 95% Confidence Interval (CI) [0.28, 2.94]. The intake of the COVID-19 vaccine, P = 0.003 and 95% CI [0.73, 3.55]; waterpipe smoking, P = 0.017 and 95% CI [0.38, 3.85]; and having more somatic complaints, P = 0.005 and 95% CI [0.04, 0.25], also were significantly associated with higher ACT scores (more uncontrolled asthma). When taking the total behavior score as an independent variable, higher YSR scores were associated with higher ACT scores (more uncontrolled asthma), F(10, 191) = 4.30, P = 0.038, and 95% CI [0.003, 0.10].

CONCLUSION

Our findings support the inclusion of mental health treatments for better asthma control and point to a link between behavioral issues and uncontrolled asthma. In a developing nation without a clear established strategy for asthma prevention, the findings of this study could help develop potentially beneficial public health treatments.

Administration of BNT162b2 mRNA COVID-19 vaccine to subjects with various allergic backgrounds

Background

The mRNA-based COVID-19 vaccine was introduced to the general public in December 2020. Shortly thereafter, safety concerns were raised due to the reporting of allergic reactions. Allergy-related disorders were suspected to be significant risk factors and the excipient polyethylene glycol was suggested to be a robust allergen.

Methods

This is a retrospective study analysis. Subjects with putative risk factors for severe allergic reactions to the Pfizer-BioNTech BNT162b2 vaccine were referred for vaccination under observation at the Unit of Allergy and Clinical Immunology. Data was collected for each subject, including demographic details, medical history and previous reactions to any allergen. When appropriate, skin tests were done prior to vaccination.

Results

A total of 346 subjects received 623 vaccine doses under observation. The study included patients with various allergy-related disorders (n=290) and those with allergy to a previous COVID-19 vaccine dose (n=56). Both groups showed female predominance (78% and 88%, p=NS). Patients without reactions to previous doses reported more drug allergy (80% vs. 39%, p<0.001) and previous anaphylaxis (64% vs. 14%, p<0.001). There was no difference in sensitivity to other allergens, including polyethylene glycol. Under observation, mild allergic reactions were noted in 13 individuals characterized by female gender (100%), a history of anaphylaxis (69%) and drug allergy (62%). In 7 subjects, allergy was treated with antihistamines while others recovered spontaneously.

Conclusion

Our study demonstrates that vaccination under specialist-supervision is a powerful tool for reducing over-diagnosis of systemic reactions and for rapid and reliable collection of vaccine safety data.

Knife's edge: Balancing immunogenicity and reactogenicity in mRNA vaccines

Since the discovery of messenger RNA (mRNA), there have been tremendous efforts to wield them in the development of therapeutics and vaccines. During the COVID-19 pandemic, two mRNA vaccines were developed and approved in record-breaking time, revolutionizing the vaccine development landscape. Although first-generation COVID-19 mRNA vaccines have demonstrated over 90% efficacy, alongside strong immunogenicity in humoral and cell-mediated immune responses, their durability has lagged compared to long-lived vaccines, such as the yellow fever vaccine. Although worldwide vaccination campaigns have saved lives estimated in the tens of millions, side effects, ranging from mild reactogenicity to rare severe diseases, have been reported. This review provides an overview and mechanistic insights into immune responses and adverse effects documented primarily for COVID-19 mRNA vaccines. Furthermore, we discuss the perspectives of this promising vaccine platform and the challenges in balancing immunogenicity and adverse effects.

[Vaccination approach in patients with an allergic reaction to COVID-19 vaccines or at risk of developing allergic reactions]

Introduction

There is consensus that patients at risk of developing an allergic reaction to COVID-19 vaccines should be evaluated by an immunologist-allergist to determine whether vaccination should be recommended. We wanted to share our experiences in the management of these high-risk patients, from diagnostic tests in allergological evaluation to the vaccination process.

Materials and Methods

Our retrospective cross-sectional study included patients who had previously developed an allergic reaction to COVID-19 vaccines or drugs and therefore were referred to our allergy and immunology clinic. Prick and intradermal tests were performed on all patients with methylprednisolone acetate (Depo-Medrol®, Pfizer) 40 mg/mL containing polyethylene Glycol (PEG) and triamcinolone acetonide (Kenacort®, Deva) 40 mg/mL containing polysorbate 80. While vaccination with desensitization was recommended for all patients with positive skin tests, split-dose vaccination was recommended for patients with negative skin tests. After explaining the risks and benefits, the choice of the vaccine (Pfizer/BioNTech or Sinovac/ CoronoVac) was left to the patients' discretion.

Result

A total of 41 patients, 10 males, and 31 females, with a mean age of 42.37 ± 14.177 years were included. Eighteen patients with a history of allergy after COVID-19 vaccines were analyzed according to the type of reaction and type of vaccine administered (Pfizer/BioNTech/Coronovac; Anaphylaxis: 4/1, Urticaria: 11/2). Moreover, there was a history of drug allergy in 23 patients who had not been vaccinated before. Skin tests with PEG were positive in a total of seven patients while skin tests with polysorbate 80 were negative in all patients. No allergic reaction developed in seven patients who underwent desensitization and in 34 patients who received a split dose.

Conclusions

Considering the potentially life-saving benefits of vaccination in a global pandemic environment, it is a safe and effective method to administer vaccines to at-risk patients using desensitization or split dosing techniques, based on their sensitivity status determined through a PEG skin test. This approach allows for the avoidance of preventing access to vaccines, while still ensuring the safety of patients.

COVID-19 vaccine provocation test outcome in high-risk allergic patients: A retrospective study from a tertiary hospital in Indonesia

Background

High COVID-19 vaccine coverage is essential. Patients who are considered high risk for hypersensitivity reactions and have had an allergic reaction to the COVID-19 vaccine are usually referred to an allergist for assessment of vaccination. Administration of a vaccine graded challenge (also known as a provocation test) is an option that can be considered in this population. This primary objective of this study is to describe the outcome of the COVID-19 vaccine provocation test and to understand the predicting factors associated with hypersensitivity reaction after the provocation test as the secondary objective.

Methods

Adult patients with a history of hypersensitivity reaction to the first COVID-19 vaccine and high-allergic patients who underwent COVID-19 vaccine provocation test up until May 2022 were included. A protocol using skin prick test (SPT), intradermal test (IDT), followed by graded challenge was developed for the determined vaccine used.

Results

A total of 232 patients were included in the analysis. Twenty-eight had hypersensitivity to their first COVID-19 vaccine dose and 204 were high risk for allergic reaction. Hypersensitivity reactions occurred in 20 patients (8.6%, 95% CI: 5-12.2%), consisting of 4 reactions after SPT, 9 after IDT, 7 during or after titrated challenge. Half of the reactions were mild; however, 3 patients developed severe reactions. Patients with history of anaphylaxis were more likely to experience hypersensitivity reaction after provocation test (aRR = 2.79, 95% CI: 1.05-7.42).

Conclusion

Provocation test in COVID-19 vaccination has a high success rate in patients with a history of hypersensitivity to the first COVID-19 vaccine and in high allergic patients. History of anaphylaxis is associated with hypersensitivity reaction after a COVID-19 vaccine provocation test.

Reporting of Allergic Reactions During Pfizer-BioNTech BNTT162B2 Vaccination in Israel

Background

In December 2020, the Israeli Ministry of Health launched a national vaccination campaign against SARS-CoV-2. Concomitant sporadic reports on anaphylactic responses in other countries raised safety concerns at the outset of this operation.

Objective

To characterize reports on allergic reactions to coronavirus disease 2019 vaccines.

Methods

Allergy events were reported by health care professionals throughout the country to Israeli Ministry of Health Division of Epidemiology via a Web-based computerized national vaccine registry. The study period was from December 19, 2020 to September 13, 2021, during which 14,475,979 injections were administered.

Results

Allergic reactions were reported in 463 subjects, 99.3% of whom received Pfizer-BioNTech BNTT162B2. The reporting rate was 106 per million in December 2020. From January to May 2021, a reduction was observed to 66, 18, 14, eight, and zero per million, and reporting remained low until September. Mean age of subjects was 48.9 ± 16.7 years (range, 15-96 years) with a female preponderance of 78%. Epinephrine was administered in 34 subjects. Validated immediate allergy was observed in only 37 cases (8%), suggesting 2.5 to 3.3 bona fide reactions per million. In subjects with reactions classified as severe (n = 46), plausible allergy was identified in 36% to 41% of cases. A history of allergy was associated with high false reporting of immediate reactions (83%). Allergic events after the first dose did not compromise adherence to subsequent doses.

Conclusions

Excessive reporting of allergy declined over time and did not affect adherence to vaccination. The existence of previous allergy may affect reporting profiles, but not the occurrence of vaccine allergy.

Allergic Reactions to COVID-19 Vaccines: Risk Factors, Frequency, Mechanisms and Management

Conventional vaccines have been widely studied, along with their risk of causing allergic reactions. These generally consist of mild local reactions and only rarely severe anaphylaxis. Although all the current COVID-19 vaccines marketed in Europe have been shown to be safe overall in the general population, early post-marketing evidence has shown that mRNA-based vaccines using novel platforms (i.e., lipid nanoparticles) were associated with an increased risk of severe allergic reactions as compared to conventional vaccines. In this paper we performed an updated literature review on frequency, risk factors, and underlying mechanisms of COVID-19 vaccine-related allergies by searching MEDLINE and Google Scholar databases. We also conducted a qualitative search on VigiBase and EudraVigilance databases to identify reports of “Hypersensitivity” and “Anaphylactic reaction” potentially related to COVID-19 vaccines (Comirnaty, Spikevax, Vaxzevria and COVID-19 Janssen Vaccine), and in EudraVigilance to estimate the reporting rates of “Anaphylactic reaction” and “Anaphylactic shock” after COVID-19 vaccination in the European population. We also summarized the scientific societies’ and regulatory agencies’ recommendations for prevention and management of COVID-19 vaccine-related allergic reactions, especially in those with a history of allergy.

COVID-19 Vaccines: Bioethical Consideration

The COVID-19 pandemic produced immeasurable impacts on the economy, education, and socialization, besides the loss of millions of lives. Thus, there has been an accelerated development of an unprecedented number of COVID-19 vaccine candidates to control the pandemic. The World Health Organization’s emergency use authorization of COVID-19 vaccines still in clinical trial allowed immunizing the population. This paper presents a perspective of the bioethical precepts of autonomy, non-maleficence, beneficence, and justice in the emergency use of COVID-19 vaccines. Furthermore, it emphasizes the importance of surveillance at all stages of vaccine development to detect adverse effects and ensure compliance with bioethical precepts.

Safety & effectiveness of COVID-19 vaccines: A narrative review

There are currently eight vaccines against SARS-CoV-2 that have received Emergency Use Authorization by the WHO that can offer some protection to the world's population during the COVID-19 pandemic. Though research is being published all over the world, public health officials, policymakers and governments are collecting evidence-based information to establish the public health policies. Unfortunately, continued international travel, violations of lockdowns and social distancing, the lack of mask use, the emergence of mutant strains of the virus and lower adherence by a sector of the global population that remains sceptical of the protection offered by vaccines, or about any risks associated with vaccines, hamper these efforts. Here we examine the literature on the efficacy, effectiveness and safety of COVID-19 vaccines, with an emphasis on select categories of individuals and against new SARS-CoV-2 strains. The literature shows that these eight vaccines are highly effective in protecting the population from severe disease and death, but there are some issues concerning safety and adverse effects. Further, booster shots and variant-specific vaccines would also be required.

A Case Report of Prolonged Anaphylaxis after COVID-19 Vaccine

Introduction

As the medical community and world have combatted the coronavirus disease 2019 (COVID-19) pandemic, a significant advance was the development of a vaccine against the virus that has already claimed over 4.5 million lives worldwide.1 Vaccines manufactured by Pfizer-BioNTech and Moderna were the first two COVID-19 vaccines given emergency use authorization by the United States Food and Drug Administration. Preliminary data demonstrated not only the vaccines’ efficacy rates of greater than 95% after a second dose, but also marked safety. Initial data showed only 21 cases of anaphylaxis of greater than 1.8 million doses administered. The majority of those patients had a history of anaphylaxis and presented within the first 15 minutes after administration of the vaccine.2

Case Report

We describe a patient who had an anaphylactic reaction to her second dose of the Pfizer BioNTech severe acute respiratory syndrome coronavirus 2 (SARS CoV-2) vaccine with no prior history of allergic reactions or anaphylaxis. This reaction required multiple doses of epinephrine and a four-day hospitalization. We review both the available reports of anaphylaxis to the SAR CoV-2 vaccine and information on other prolonged cases of anaphylaxis.

Conclusion

Our case report is unique in that the patient, despite no prior history of anaphylaxis, had a prolonged course requiring a four-day hospitalization. To our knowledge this is one of the first case reports of prolonged anaphylaxis after the second dose of Pfizer BioNTech COVID-19 vaccine in a patient with no history of prior anaphylaxis.3

Parents' hesitation about getting their children vaccinated against COVID-19 in Japan

Given the urgent global need for vaccinating individuals of all ages against the COVID-19 pandemic, understanding the extent and reasons for parents' willingness to get their children vaccinated is important. This study used an internet-based questionnaire survey to determine parents' willingness to get their children (0 to 15 years) vaccinated in Japan and was conducted in April 2021 before COVID-19 vaccination for children began. Socio-demographic information, information about parents' willingness to get children vaccinated, reasons for their responses, and parents' willingness to get themselves vaccinated were obtained. Descriptive statistics were used to evaluate parents' willingness to get children vaccinated based on the other variables. Logistic regression analyses were conducted to identify the characteristics of parents who indicated willingness to get their children vaccinated and to identify the reasons for vaccine willingness. Of the 1100 respondents, 472 were willing to get children vaccinated, 470 were not sure, and 158 did not want to get children vaccinated. Considerable differences were found in the willingness to get children vaccinated across gender, age groups, occupation, annual income, respondent's academic background, and respondent's willingness to get COVID-19 vaccination for themselves. Reasons for being unsure about the vaccination included the vaccine's potential side effects (84.9%), uncertainty about vaccine safety (54.7%), and not trusting vaccine efficiency (25.7%). Parents' willingness to get the COVID-19 vaccine for themselves was a significant factor for their willingness to get children vaccinated after adjusting all other factors. The study recommends disseminating more and correct information to the public to increase vaccine willingness.

Immunization practices and risk of anaphylaxis: a current update, comprehensive of COVID-19 vaccination data

PURPOSE OF REVIEW

This review aims to provide an updated report in regards to the correlation between vaccines and anaphylaxis and the related risk in the population.

RECENT FINDINGS

Initial reports showed higher incidence of anaphylaxis following messenger RNA COVID-19 vaccines compared with 'routine' vaccinations, likely influenced by the great attention paid to these 'new' vaccines. However, anaphylaxis has still to be considered quite rare and its incidence will be systematically reconsidered in the light of additional data collected.

SUMMARY

Adverse reactions to vaccines are commonly reported but most of them are nonspecific mild events, whereas vaccine-related anaphylaxis is considered a rare event, with an incidence rate equal to 1.3 cases per million vaccine doses administered. As anaphylaxis reports usually start to be reported to passive pharmacovigilance during postmarketing surveillance, the first data are used to be influenced by under- and over-reporting and lack of denominators and following studies are needed to confirm the causal relationship. This might create an initial overcautiously approach to new immunization practices but, being anaphylaxis a potential life-threatening event, every suspected contraindication has to be deepened to maximize effectiveness and safety profile and constantly redefined not to exclude an overestimated population group who could receive the vaccine uneventfully.

COVID-19 Vaccination in Patients with Severe Asthma on Biologic Treatment: Safety, Tolerability, and Impact on Disease Control

BACKGROUND

COVID-19 vaccination has been recommended for severe asthmatics. We aimed to evaluate the safety, tolerability, and impact on disease control and patient's quality of life of the mRNA SARS-CoV-2/COVID-19 vaccine in severe asthma patients regarding biologic treatment.

METHODS

Severe asthmatic patients regularly managed by two big allergy and respiratory referral centers were offered to undergo Pfizer COVID 19 vaccination at the hospital site. Patients filled in an adverse events questionnaire after the first and second dose, as well as the Asthma Control Test (ACT) and Asthma Quality of Life Questionnaire (AQLQ).

RESULTS

Overall, 253 patients were vaccinated; only 16 patients refused. No serious events were detected. Less than 20% of patients reported side effects, most of which were classified as very common side effects. No differences were reported according to the ongoing biologic drug. A significant improvement in both ACT and AQLQ was observed between the first and the second dose administration.

CONCLUSIONS

Our data confirm the optimal safety and tolerability profile of mRNA SARS- CoV-2/COVID-19 in severe asthma patients on biologic treatment, as well as their positive attitude towards COVID-19 vaccination. The negligible proportion of patients reporting side effects and the absence of asthma exacerbations are relevant to support the COVID-19 vaccination campaign in severe asthma patients worldwide.

Vaccine allergy: evidence to consider for COVID-19 vaccines

PURPOSE OF REVIEW

Whereas the COVID-19 pandemic has changed our lives worldwide, we hope that vaccination can combat the disease. We propose how to evaluate suspected severe allergic reactions to the vaccines so that as many as possible may be safely vaccinated.

RECENT FINDINGS

Rare cases of severe allergic reactions after COVID-19 vaccination have been observed, seemingly at a higher frequency than for other vaccines. Few excipients are likely to have caused these reactions. IgE-mediated reactions to polyethylene glycol (PEG) and its derivatives are the most suspected, albeit hitherto unproven, causes. We suggest to make a diagnosis based on skin tests with PEG and PEG derivatives and that these be considered in relation to the decisions required before the first and the second vaccine dose. A vaccine without these excipients is available, but published data about its side effects are limited.

SUMMARY

The underlying immunological mechanisms of the rare severe allergic reactions to the COVID-19 vaccines are poorly understood and need to be clarified. Identifying those who have an undiagnosed allergy to PEG and PEG derivatives is crucial before vaccination, and these substances are found in laxatives, cosmetics and in 30% of all our medications today.

Vaccination hesitancy and the "myth" on mRNA-based vaccines in Italy in the COVID-19 era: Does urgency meet major safety criteria?

Coronavirus disease 2019 (COVID-19) vaccination campaign in Italy has started with a huge perplexity about vaccine efficacy, vaccine-borne adverse effects and vaccine clinical trial studies. In this commentary I tried to elucidate these issues, which represent a fundamental topic to be thoroughly addressed in COVID-19 pandemic.

Adverse reactions to COVID-19 vaccines: A practical approach

COVID-19-related mortality in high-risk individuals is substantial and current treatment options are limited. There is convincing evidence that the COVID-19 vaccines reduce the severity of infection and prevent deaths. Three COVID-19 vaccines are approved in the United Kingdom with many more in development. There are limited data on the triggers and mechanisms of anaphylaxis to these vaccines. We review the potential allergenic compounds in the COVID-19 vaccines and describe an innovative allergy support model for the vaccination hubs that allows most patients with severe allergy be immunized. Finally, we propose a practical algorithm for the investigations of anaphylaxis to these vaccines.

Review the safety of Covid-19 mRNA vaccines: a review

The novel coronavirus disease 2019 (COVID-19) has infected more than 100 million people globally within the first year of the pandemic. With a death toll surpassing 500,000 in the United States alone, containing the pandemic is predicated on achieving herd immunity on a global scale. This implies that at least 70-80 % of the population must achieve active immunity against the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), either as a result of a previous COVID-19 infection or by vaccination against SARS-CoV-2. In December 2020, the first two vaccines were approved by the FDA through emergency use authorization in the United States. These vaccines are based on the mRNA vaccine platform and were developed by Pfizer/BioNTech and Moderna. Published safety and efficacy trials reported high efficacy rates of 94-95 % after two interval doses, in conjunction with limited side effects and a low rate of adverse reactions. The rapid pace of vaccine development and the uncertainty of potential long-term adverse effects raised some level of hesitation against mRNA vaccines in the global community. A successful vaccination campaign is contingent on widespread access to the vaccine under appropriate storage conditions, deployment of a sufficient number of vaccinators, and the willingness of the population to be vaccinated. Thus, it is important to clarify the objective data related to vaccine safety, including known side effects and potential adverse reactions. The present review was designed to provide an update on the current state of science related to the safety and efficacy of SARS-CoV-2 mRNA vaccines.

COVID-19 Vaccine-associated Anaphylaxis and Allergic Reactions: Consensus Statements of the KAAACI Urticaria/Angioedema/Anaphylaxis Working Group

In the era of novel coronavirus epidemics, vaccines against coronavirus disease 2019 (COVID-19) have been recognized as the most effective public health interventions to control the pandemic. An adverse event following immunization (AEFI) is defined as any untoward occurrence following immunization, and the majority of AEFIs are caused by protective immune responses stimulated by vaccines. Most of the reported AEFIs are not serious, and many are not immunologically mediated or even reproducible on re-exposure. However, uncommon severe allergic adverse reactions, such as anaphylaxis or other allergic reactions, can occur after vaccinations. Confirmed allergic reactions to vaccines may be caused by residual non-human protein, preservatives, or stabilizers in the vaccine formulation (also known as excipients). There are 2 main potential allergenic/immunogenic excipients in COVID-19 vaccines, polyethylene glycol (PEG) and polysorbate 80. PEG, also known as macrogol, is an ingredient in various laxatives and injectable formulations, such as depot steroids. Polysorbate 80 is present in various medical products, creams, ointments, lotions, and medication tablets. Contraindications to the administration of COVID-19 vaccines include a previous history of severe allergic reactions to the first dose of COVID-19 vaccine or proven hypersensitivity to a vaccine component, such as PEG or polysorbate 80. Anaphylaxis or other allergic reactions following immunization can cause fear and loss of confidence in the safety of vaccines among the public. A better understanding of these events is thought to help alleviate concerns about the current COVID-19 vaccines and provide reassurance to the general population by analyzing the exact incidence of anaphylaxis and potential risk factors. COVID-19 vaccine-associated anaphylaxis could be prevented and managed by risk stratification based on our local and global experience.