Bone erosion and subacromial bursitis caused by diphtheria-tetanus-poliomyelitis vaccine

What three years of COVID-19 vaccine administration reveals about the incidence of shoulder injury related to vaccine administration (SIRVA)

BACKGROUND

Shoulder injury related to vaccine administration (SIRVA) has been reported to be a rare but real complication of vaccination. It is considered attributable to an incorrect vaccine administration technique by the vaccinator. To date, evidence about SIRVA is mainly limited to case studies and case series, and the incidence remains unknown. This study aimed to determine the incidence of SIRVA.

METHODS

We conducted a retrospective study of the publicly available Eudravigilance database (pharmacovigilance data). We examined all COVID-19 vaccine case reports administered between January 2020 and December 2022. Reports were analysed to see if they met the Surveillance of Adverse Events Following Vaccination In the Community (SAEFVIC) definition and inclusion criteria for SIRVA. Data was extracted.

FINDINGS

Between January 2020, and December 2022, from 1,172,583,008 administered COVID-19 vaccines, 43,192 cases met the SAEFVIC inclusion criteria for SIRVA. This equals an incidence of 3·7 cases per 100,000 vaccines administered during the three years. Female subjects are disproportionately affected, with 33,828 cases (77.9 %). The incidence was higher with some COVID-19 vaccine formulations than others.

INTERPRETATION

The incidence found in this study is higher than previously reported. The data also reflects that it affects more female subjects than males. While previously considered avoidable using the correct vaccine administration technique, the data challenges this notion as it shows that certain vaccine formulations may be associated with a higher incidence of the condition. The causes of SIRVA are likely multifaceted, with current understanding being further impacted by unclear definitions and reporting requirements.

FUNDING

This project was supported by an ECARD grant from The University of Canberra.

Chronic stage magnetic resonance imaging findings in patients with shoulder injury related to vaccine administration (SIRVA)

PURPOSE

Identify chronic shoulder MRI findings in patients with known shoulder injury related to vaccine administration (SIRVA).

MATERIALS AND METHODS

Two fellowship-trained musculoskeletal radiologists retrospectively reviewed the MRI of nine patients with clinically established SIRVA. MRI was performed at least 4 weeks after vaccination and included intravenous contrast-enhanced sequences. MRI was reviewed for the presence of erosions, tendonitis, capsulitis, synovitis, bone marrow oedema, joint effusion, bursitis, cartilage defects, rotator cuff lesions, and lymphadenopathy. The number and location of focal lesions were recorded.

RESULTS

Erosions of the greater tuberosity were present in 8/9 (89%), tendonitis of the infraspinatus muscle tendon in 7/9 (78%), capsulitis, synovitis, and bone marrow oedema in 5/9 (56%) cases, respectively. Effusion was found in three, and subdeltoid bursitis, rotator cuff lesions as well as cartilage defects in one patient, respectively. None of our included subjects showed axillary lymphadenopathy.

CONCLUSION

In this case series, greater humeral tuberosity erosions, infraspinatus muscle tendonitis, capsulitis, synovitis, and bone marrow oedema were common MRI findings in chronic SIRVA.

Adhesive Capsulitis Secondary to COVID-19 Vaccination - A Case Series

Introduction

Shoulder injury related to vaccine administration (SIRVA) is a group of pathologies defined by pain and stiffness after intramuscular administration of vaccine to the upper arm and has been reported after COVID-19 vaccination. We aim to discuss its pathophysiology, clinical presentation, treatment and outcomes.

Materials and methods

We retrospectively identified patients presenting with adhesive capsulitis within four weeks of administration of COVID-19 vaccine to the affected arm at our tertiary institution from March 2021 to December 2022.

Result

Based on the above criteria, we identified seven cases of adhesive capsulitis, comprising one male and six female patients, with average age of 60 years. We present initial symptoms, signs and the duration from when the vaccine was administered. We have highlighted our treatment strategies as well as the clinical and functional outcomes reported by these patients after treatment. We have reported improvement in both Visual Analogue Scale (VAS) and range of motion (ROM) in all our patients after non-surgical management which included physiotherapy and, in some cases, hydrodilatation.

Conclusion

SIRVA related adhesive capsulitis is rare and under-reported with limited information in current literature. This study highlights that adhesive capsulitis is a potential complication arising from improper COVID-19 vaccine administration and reinforces traditional wisdom of administering vaccinations on the non-dominant arm. Conservative treatment strategies appear to be effective, particularly hydrodilatation combined with physiotherapy, and patients are expected to have a good return of function.

Atypical progress of frozen shoulder after COVID-19 vaccination: A case report

BACKGROUND

After vaccination was mandated worldwide, various adverse effects associated with the coronavirus disease 2019 (COVID-19) vaccination, including shoulder pain, have been reported. Here, we report a case of new-onset shoulder pain after BNT162b2 (Comirnaty, Pfizer-BioNTech) mRNA vaccination.

CASE SUMMARY

A 50-year-old man visited our rehabilitation center with left shoulder range of motion (ROM) limitation that had persisted for more than 5 mo. The history included no specific noteworthy events, except vaccination. The pain in the patient's left deltoid muscle appeared 1 day after the second BNT162b2 vaccination and intensified to severe pain. The patient self-administered aspirin, with which the pain subsided immediately, whereas ROM limitation persisted. At the first visit, the patient complained of dull pain and ROM restriction of the left shoulder (flexion 130°, abduction 110°, and external rotation 40°). Among the diagnostic studies conducted for the evaluation of the shoulder, magnetic resonance imaging showed a thickened coracohumeral ligament. Nerve conduction studies and needle electromyography showed no electrodiagnostic abnormalities. The patient received comprehensive rehabilitation for 7 mo and had an overall improvement in pain and ROM of the left shoulder.

CONCLUSION

In this case of severe shoulder pain after COVID-19 vaccination that subsided immediately with aspirin treatment, the exact cause and mechanism of pain are unclear. However, the clinical symptoms and diagnostic workups in our report suggest the possibility that the COVID-19 vaccination triggered an immunochemical response that resulted in shoulder pathology.

Shoulder Injury Related to Vaccine Administration: Case Series

Objective  Shoulder pain is a common presentation in the primary care setting, and shoulder pain after vaccination has a growing body of literature. The present study sought to understand how a standardized treatment protocol would aid patients experiencing shoulder injury related to vaccine administration (SIRVA). Methods  Patients experiencing SIRVA were retrospectively recruited between February 2017 and February 2021. All patients were treated with physical therapy and offered a cortisone injection. Post-treatment range of motion (i.e., forward elevation, external rotation, internal rotation) and patients' reported outcomes were collected with the visual analogue scale (VAS), American Shoulder and Elbow Surgeons (ASES), simple shoulder test (SST), and single assessment numeric evaluation (SANE) scores. Results  A total of 9 patients were retrospectively examined. Among them, 6 patients presented within one month of a recent vaccination event, while 3 patients presented 67, 87, and 120 days after vaccination. Furthermore, 8 of the patients completed physical therapy, and 6 of them underwent a cortisone injection. The follow-up time averaged 8 months. At final follow-up, the mean external rotation was 61° (standard deviation, SD ± 3°) and the mean forward elevation was 179° (SD ± 45°). Internal rotation ranged between L3 and T10. The VAS pain scores were 3.5/10.0 (SD ± 2.4), the mean ASES score was 63.5/100.0 (SD ± 26.3), and the SST scores were 8.5/12.0 (SD ± 3.9). Finally, the SANE scores were 75.7/100.0 (SD ± 24.7) and 95.7/100.0 (SD ± 6.1) in the injured and contralateral shoulders respectively. Conclusion  Shoulder pain after a vaccination treated with physical therapy and cortisone injection ultimately resulted in favorable shoulder range of motion and functional score outcomes. Level of Evidence  IV.

Emergency Department Treatment Provides Immediate and Durable Relief Following Vaccine Injury: A Case Report

INTRODUCTION

Intramuscular administration of vaccines into the deltoid muscle is the recommended route for most vaccines in adults. Ectopic injection into the subdeltoid/subacromial bursa can produce an inflammatory bursitis that is associated with significant long-term morbidity.

CASE REPORT

We describe a novel approach to treatment of this condition: ultrasound-guided administration of dexamethasone by the emergency physician within six hours of vaccine administration. This approach resulted in complete and durable long-term resolution of symptoms with no functional impairment.

CONCLUSION

This outcome is superior to that described for usual care, and the approach is well-suited to emergency physicians.

Shoulder Pain and Dysfunction After Vaccination: A Systematic Review

BACKGROUND

Persistent shoulder pain and dysfunction after vaccination are relatively rare but well-known complications after inoculations into the deltoid muscle. The term SIRVA (shoulder injury related to vaccine administration) is frequently used to encompass many of these occurrences; however, multiple distinct pathologies with similar presentations have been reported after vaccination. We performed a systematic review of the literature on vaccine-related shoulder injuries to help guide practitioners in appropriate workup and treatment based on specific diagnoses.

METHODS

PubMed was used to search for combinations of multiple keywords (including vaccine, immunization, SIRVA, injury, inflammation, bursitis, Parsonage-Turner syndrome, and neuritis), and all references of each potential article were reviewed. A total of 56 articles were included. Patient demographics, vaccine information, presentation, diagnostic studies, treatment, and outcomes were recorded.

RESULTS

Diagnoses were divided into 3 categories: (1) local inflammatory reaction (SIRVA), (2) brachial neuritis, and (3) direct nerve injury. The included articles reported on 57 cases of SIRVA, 18 of brachial neuritis, and 4 of direct nerve injury. The diagnoses reported for the SIRVA cases included frozen shoulder, pseudoseptic arthritis, subacromial bursitis, rotator cuff injury, and lytic lesions of the humeral head. Various treatments were used, and most patients had resolution of symptoms with conservative treatment including physical therapy, analgesics, and/or corticosteroid injections. Advanced imaging rarely provided information that affected treatment. The brachial neuritis and direct nerve injury cases were typically confirmed with electromyography/nerve conduction studies. Treatment of these 2 categories was nonoperative in all cases, typically with analgesics and/or corticosteroids, and most patients had symptomatic improvement after a few months, with most patients regaining strength. However, some (1 of 3 patients with brachial neuritis and >1 year of follow-up and 2 of 4 patients with direct injury) had residual weakness.

CONCLUSIONS

Medical professionals should be aware of the various pathologies that can lead to prolonged shoulder pain after vaccination. Fortunately, most of these conditions can be treated successfully with nonoperative modalities, although differentiating among the diagnoses can help guide treatment, as some likely benefit from systemic corticosteroids or localized corticosteroid injections. Outcomes for most patients have been good, with the majority recovering without residual pain or deficits.

LEVEL OF EVIDENCE

Prognostic Level IV.

What Do We Know About Shoulder Injury Related to Vaccine Administration? An Updated Systematic Review

BACKGROUND

Shoulder injury related to vaccine administration (SIRVA) is postulated to be an immune-mediated inflammatory response to a vaccine antigen injected into or near the subacromial bursae or synovium, leading to shoulder pain and dysfunction. The number of studies on this topic is rapidly increasing. Recent comparative studies have reported conflicting conclusions, which suggests that a systematic review of the best-available evidence may be helpful.

QUESTIONS/PURPOSES

In this systematic review, we asked: What are the (1) clinical characteristics, (2) diagnoses, and (3) management approaches and outcomes reported in association with SIRVA?

METHODS

A search was performed on October 4, 2021, of the PubMed and Medline databases for studies related to SIRVA. Inclusion criteria were English-language comparative studies, case series, and case reports that involved shoulder pain occurring after vaccination. Studies of exclusively neurologic conditions after vaccination were excluded. Forty-two studies met the eligibility criteria, including three retrospective comparative studies (72 patients and 105 controls), five database case series (2273 patients), and 34 case reports (49 patients). Study quality was assessed for the database case series and retrospective comparative studies using the Methodological Index for Non-randomized Studies tool.

RESULTS

Among patients in the case reports, the median age was 51 years (range 15-90 years), and 73% (36 of 49) were women. BMI was reported for 24% of patients (12 of 49) in case reports, with a median of 23.5 kg/m2 (range 21-37.2 kg/m2). The most common symptoms were shoulder pain and reduced ROM. The most common diagnoses were shoulder bursitis, adhesive capsulitis, and rotator cuff tears. The most frequent management modalities included physical or occupational therapy, NSAIDs, and steroid injections, followed by surgery, which was generally used for patients whose symptoms persisted despite nonsurgical management. Full resolution of symptoms was reported in 2.9% to 56% of patients.

CONCLUSION

The association between inflammatory conditions of the shoulder (such as bursitis) and vaccination appears to be exceedingly rare, occurring after approximately 1:130,000 vaccination events according to the best-available comparative study. Currently, there is no confirmatory experimental evidence supporting the theory of an immune-mediated inflammatory response to vaccine antigens. Although the clinical evidence is limited, similar to any bursitis, typical treatments appear effective, and surgery should rarely be performed. Additional research is needed to determine the best injection technique or evaluate alternate injection sites such as the anterolateral thigh that do not involve positioning a needle close to the shoulder.

Persistent Shoulder Pain After Vaccine Administration Is Associated with Common Incidental Pathology: A Systematic Review

BACKGROUND

Claims of shoulder injury now account for half of all claims to the Vaccine Injury Compensation Program. Reports from databases of claims or potential adverse events note a relatively high mean age and high prevalences of rotator cuff tendinopathy and adhesive capsulitis-common shoulder problems that might be incidental to vaccination. Published case reports provide much more detail about individual patients than is available in databases. A review of published cases provides an opportunity for more detailed review of symptoms, diagnoses, pathology, treatment, and prognosis. Such a review can better assess the relative likelihood that pathologies associated with new persistent shoulder symptoms after vaccination are coincidental or unique to and caused by vaccine.

QUESTIONS/PURPOSES

Regarding published case reports addressing persistent shoulder pain after vaccination: (1) In what proportion of patients was a specific diagnosis made? (2) What diagnoses were most common? (3) Among patients treated nonsurgically, what proportion resolved, and over what time span did they resolve?

METHODS

In August 2020, we searched PubMed and Embase between 2006 and 2020 using the following search strategy: Search 1: (shoulder dysfunction OR shoulder pain OR shoulder bursitis OR rotator cuff tendonitis OR adhesive capsulitis OR glenohumeral arthritis AND [vaccine OR vaccination OR immunization]); Search 2: (shoulder injury related to vaccine administration or SIRVA). The search was supplemented by reviewing reference lists of identified studies. Inclusion criteria were any detailed report of three or fewer cases involving shoulder pain after vaccine administration. Twenty published reports of 29 patients were identified and assessed by two reviewers independently. One reported glenohumeral joint infection was excluded because the relationship between this type of relatively uncommon, discrete diagnosis and vaccination raises different considerations. We assumed a high risk of bias, although we are not aware of bias assessment tool for case reports. We recorded and summarized patient demographics, symptoms, examination and imaging findings, surgery findings, diagnoses, treatments, and outcomes. Seventy-five percent (21 of 28) of patients were women, with a mean age of 54 ± 19 years. In search of an underlying pathology, at least one diagnostic study was performed in 82% (23 of 28) of patients including radiographs in seven, ultrasound in seven, and MRI in 16 patients (some patients underwent more than one type of imaging). We distinguished specific pathophysiological diagnosis from shoulder pain and stiffness, counted the most common diagnoses among patients a specific diagnosis, and tracked symptom resolution among patients treated nonoperatively.

RESULTS

A specific diagnosis was made in 57% (16 of 28) of patients. Twelve patients had pain and limitation of motion due to pain but no specific pathological diagnosis. The most common specific diagnoses were rotator cuff tendinopathy (9 of 16) and adhesive capsulitis (4 of 16). Less common specific diagnoses included rotator cuff arthropathy (and rheumatoid arthritis) and suspected septic arthritis with nonspecific synovitis on arthroscopy. One patient had transient MRI signal change in the humeral head, which was interpreted as osteonecrosis that resolved in a manner not typical for that diagnosis. Of the 17 patients treated nonsurgically, 15 reported resolution, and two had incomplete symptom resolution with the mean 6-month evaluation period.

CONCLUSION

The observation that persistent shoulder pain after vaccination overlaps with common shoulder pathology-both in large databases as well as in more detailed reports of specific patients as analyzed in this review-establishes a high probability of a coincidental rather than a causal association. In the absence of high-quality experimental evidence of vaccine-specific shoulder pathology, in our opinion, it seems safest and healthiest to assume that perceived shoulder injury related to vaccine administration (SIRVA) is due to misinterpretation of new symptoms from established pathology rather than a new, vaccine-specific pathology.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

Risk for Shoulder Conditions After Vaccination: A Population-Based Study Using Real-World Data

BACKGROUND

Although shoulder conditions have been reported as an adverse event after intramuscular vaccination in the deltoid muscle, epidemiologic data on shoulder conditions after vaccination are limited.

OBJECTIVE

To estimate the risk for shoulder conditions after vaccination and assess possible risk factors.

DESIGN

Retrospective cohort study.

SETTING

Kaiser Permanente Southern California, a large integrated health care organization.

PARTICIPANTS

Kaiser Permanente Southern California members aged 3 years or older who had an intramuscular vaccination administered in the deltoid muscle between 1 April 2016 and 31 December 2017.

MEASUREMENTS

A natural language processing (NLP) algorithm was used to identify potential shoulder conditions among vaccinated persons with shoulder disorder diagnosis codes. All NLP-identified cases were manually chart confirmed on the basis of our case definition. The characteristics of vaccinated persons with and without shoulder conditions were compared.

RESULTS

Among 3 758 764 administered vaccinations, 371 cases of shoulder condition were identified, with an estimated incidence of 0.99 (95% CI, 0.89 to 1.09) per 10 000 vaccinations. The incidence was 1.22 (CI, 1.10 to 1.35) for the adult (aged ≥18 years) and 0.05 (CI, 0.02 to 0.14) for the pediatric (aged 3 to 17 years) vaccinated populations. In the adult vaccinated population, advanced age, female sex, an increased number of outpatient visits in the 6 months before vaccination, lower Charlson Comorbidity Index, and pneumococcal conjugate vaccine were associated with a higher risk for shoulder conditions. Among influenza vaccines, quadrivalent vaccines were associated with an increased risk for shoulder conditions. Simultaneous administration of vaccines was associated with a higher risk for shoulder conditions among elderly persons.

LIMITATION

Generalizability to other health care settings, use of administrative data, and residual confounding.

CONCLUSION

These population-based data suggest a small absolute risk for shoulder conditions after vaccination. Given the high burden of shoulder conditions, clinicians should pay attention to any factors that may further increase risks.

PRIMARY FUNDING SOURCE

Centers for Disease Control and Prevention.

Shoulder Injury Related to Vaccine Administration and a Growing Challenge: A Focused Review

ABSTRACT

Shoulder injury related to vaccine administration (SIRVA), an entity that causes acute shoulder pain and may limit range of motion (ROM) after vaccination, is a condition where a small but significant percentage of patients are experiencing in light of the current push for mass immunizations against SARS-CoV-2 worldwide. A search of literature related to SIRVA was performed across multiple electronic databases. Women, patients reporting vaccine injection location to be too high, and patients without prior history of shoulder pain were the most common historical factors in those experiencing SIRVA. Tenderness to palpation and limited shoulder ROM were the most associated physical examination findings. When using magnetic resonance imaging, tendinopathy, subacromial-subdeltoid bursitis, and rotator cuff tears (partial or complete) were the most common findings. Radiographic imaging rarely aided the diagnosis. SIRVA is an entity that health care providers should be aware of to improve the care of patients that may experience these symptoms after vaccine administration.

Chronic inflammation and extracellular matrix-specific autoimmunity following inadvertent periarticular influenza vaccination

BACKGROUND

Viral infections may trigger autoimmunity in genetically predisposed individuals. Immunizations mimic viral infections immunologically, but only in rare instances vaccinations coincide with the onset of autoimmunity. Inadvertent vaccine injection into periarticular shoulder tissue can cause inflammatory tissue damage ('shoulder injury related to vaccine administration, SIRVA). Thus, this accident provides a model to study if vaccine-induced pathogen-specific immunity accompanied by a robust inflammatory insult may trigger autoimmunity in specific genetic backgrounds.

METHODS

We studied 16 otherwise healthy adults with suspected SIRVA occurring following a single work-related influenza immunization campaign in 2017. We performed ultrasound, immunophenotypic analyses, HLA typing, and influenza- and self-reactivity functional immunoassays. Vaccine-related bone toxicity and T cell/osteoclast interactions were assessed in vitro.

FINDINGS

Twelve of the 16 subjects had evidence of inflammatory tissue damage on imaging, including bone erosions in six. Tissue damage was associated with a robust peripheral blood T and B cell activation signature and extracellular matrix-reactive autoantibodies. All subjects with erosions were HLA-DRB1*04 positive and showed extracellular matrix-reactive HLA-DRB1*04 restricted T cell responses targeting heparan sulfate proteoglycan (HSPG). Antigen-specific T cells potently activated osteoclasts via RANK/RANK-L, and the osteoclast activation marker Trap5b was high in sera of patients with an erosive shoulder injury. In vitro, the vaccine component alpha-tocopheryl succinate recapitulated bone toxicity and stimulated osteoclasts. Auto-reactivity was transient, with no evidence of progression to rheumatoid arthritis or overt autoimmune disease.

CONCLUSION

Vaccine misapplication, potentially a genetic predisposition, and vaccine components contribute to SIRVA. The association with autoimmunity risk allele HLA-DRB1*04 needs to be further investigated. Despite transient autoimmunity, SIRVA was not associated with progression to autoimmune disease during two years of follow-up.

Identifying Cases of Shoulder Injury Related to Vaccine Administration (SIRVA) in the United States: Development and Validation of a Natural Language Processing Method (Preprint)

Background

Shoulder injury related to vaccine administration (SIRVA) accounts for more than half of all claims received by the National Vaccine Injury Compensation Program. However, due to the difficulty of finding SIRVA cases in large health care databases, population-based studies are scarce.

Objective

The goal of the research was to develop a natural language processing (NLP) method to identify SIRVA cases from clinical notes.

Methods

We conducted the study among members of a large integrated health care organization who were vaccinated between April 1, 2016, and December 31, 2017, and had subsequent diagnosis codes indicative of shoulder injury. Based on a training data set with a chart review reference standard of 164 cases, we developed an NLP algorithm to extract shoulder disorder information, including prior vaccination, anatomic location, temporality and causality. The algorithm identified 3 groups of positive SIRVA cases (definite, probable, and possible) based on the strength of evidence. We compared NLP results to a chart review reference standard of 100 vaccinated cases. We then applied the final automated NLP algorithm to a broader cohort of vaccinated persons with a shoulder injury diagnosis code and performed manual chart confirmation on a random sample of NLP-identified definite cases and all NLP-identified probable and possible cases.

Results

In the validation sample, the NLP algorithm had 100% accuracy for identifying 4 SIRVA cases and 96 cases without SIRVA. In the broader cohort of 53,585 vaccinations, the NLP algorithm identified 291 definite, 124 probable, and 52 possible SIRVA cases. The chart-confirmation rates for these groups were 95.5% (278/291), 67.7% (84/124), and 17.3% (9/52), respectively.

Conclusions

The algorithm performed with high sensitivity and reasonable specificity in identifying positive SIRVA cases. The NLP algorithm can potentially be used in future population-based studies to identify this rare adverse event, avoiding labor-intensive chart review validation.

Progressive Monoarticular Inflammatory Arthritis Following Influenza Vaccination

Musculoskeletal injury is an uncommon but usually self-limited complication of vaccine administration. We present a case of progressive inflammatory monoarthritis of the shoulder characterized by bone erosion, bursitis, and severe synovitis caused by an influenza vaccine administered to the ipsilateral deltoid region. Clinical symptoms began within 2 hours of vaccination, with progressive decline in function over 6 weeks. Magnetic resonance imaging examinations performed 5 months apart demonstrated progressive erosive changes of the greater tuberosity, rotator cuff injury, and extensive enhancing synovitis of the glenohumeral joint and subacromial/subdeltoid bursa. After the exclusion of septic arthritis and osteomyelitis, the patient underwent nonoperative treatment and experienced near-complete recovery at 32 months. Although inflammatory arthritis of the shoulder following vaccination is rare, there have been previous reports of it. Clinicians and radiologists need to be aware of this potential complication to ensure an accurate diagnosis.

Shoulder Injury after Vaccination: A Systematic Review

Adverse reactions to vaccine injections are usually mild and incredibly rare in nature, but multiple cases of shoulder events including bursitis, generalized pain or decreased range of motion have been reported following routine vaccine administrations. These events are known as Shoulder Injury Related to Vaccine Administration or SIRVA. A systematic review of literature was performed to identify all published accounts of SIRVA. Twenty-seven papers reporting one or more accounts of SIRVA were identified. The most common vaccination involved was the Influenza vaccine. The most common symptoms were pain that began in 48 hours or less and loss of shoulder range of motion. The most common treatment modalities were physical therapy, corticosteroid injections and anti-inflammatory medication; but in some patients, surgery was required. Regardless of intervention, the vast majority of outcomes demonstrated improved pain and functional except in the occasions of nerve injury. The etiology of SIRVA injuries has multiple possibilities including needle length, mechanical injury from needle overpenetration and the possibility of an immune inflammatory response from the vaccine components, but a unique definitive test or quantifiably result does not yet exist.

Risk for Subdeltoid Bursitis After Influenza Vaccination: A Population-Based Cohort Study

BACKGROUND

Subdeltoid bursitis has been reported as an adverse event after intramuscular vaccination in the deltoid muscle. Most published case reports involved influenza vaccine.

OBJECTIVE

To estimate the risk for subdeltoid bursitis after influenza vaccination.

DESIGN

Retrospective cohort study.

SETTING

The Vaccine Safety Datalink, which contains health encounter data for 10.2 million members of 7 U.S. health care organizations.

PATIENTS

Persons who received an inactivated influenza vaccine during the 2016-2017 influenza season.

MEASUREMENTS

Potential incident cases were identified by searching administrative data for persons with a shoulder bursitis diagnostic code within 180 days after receiving an injectable influenza vaccine in the same arm. The date of reported bursitis symptom onset was abstracted from the medical record. A self-controlled risk interval analysis was used to calculate the incidence rate ratio of bursitis in a risk interval of 0 to 2 days after vaccination versus a control interval of 30 to 60 days, which represents the background rate. The attributable risk was also estimated.

RESULTS

The cohort included 2 943 493 vaccinated persons. Sixteen cases of symptom onset in the risk interval and 51 cases of symptom onset in the control interval were identified. The median age of persons in the risk interval was 57.5 years (range, 24 to 98 years), and 69% were women. The incidence rate ratio was 3.24 (95% CI, 1.85 to 5.68). The attributable risk was 7.78 (CI, 2.19 to 13.38) additional cases of bursitis per 1 million persons vaccinated.

LIMITATION

The results may not be generalizable to vaccinations done in other types of health care settings.

CONCLUSION

Although an increased risk for bursitis after vaccination was present, the absolute risk was small.

PRIMARY FUNDING SOURCE

Centers for Disease Control and Prevention.

Teres minor injury related to vaccine administration

Shoulder injury related to vaccine administration is a relatively rare disorder, which occurs as a result of vaccine being inadvertently injected into the subdeltoid/subacromial bursa, rotator cuff, and or underlying bone. We present 2 cases of shoulder injury related to vaccine administration in 2 women of ages 38 and 42 with injury to the teres minor tendon insertions on magnetic resonance imaging, a location not previously described. When faced with a patient with chronic shoulder pain following a vaccination, the possibility of vaccine deposition or injury to the teres minor tendon insertion should be considered.

Shoulder Injury Related to Vaccine Administration (SIRVA): Petitioner claims to the National Vaccine Injury Compensation Program, 2010-2016

BACKGROUND

Since 2010, petitioner claims of shoulder injury related to vaccine administration (SIRVA) to the National Vaccine Injury Compensation Program (VICP) have been increasing.

OBJECTIVE

To conduct a scientific review of clinical characteristics of SIRVA petitions to the VICP.

METHODS

We queried the VICP's Injury Compensation System database for medical reports of alleged SIRVA and SIRVA-like injuries. Medical reports are summaries of petitioner claims and supporting documentation along with a VICP clinician reviewer diagnosis and assessment of criteria for concession. We conducted a descriptive analysis of SIRVA petitioner claims recommended by the VICP for concession as SIRVA injuries.

RESULTS

We identified 476 petitioner claims recommended for concession. Claims per year increased from two in 2011, the first full year in the analytic period, to 227 in 2016. Median age was 51 years, 82.8% were women, and median body mass index was 25.1 (range 17.0-48.9). Four hundred cases (84.0%) involved influenza vaccine. Pharmacy or store (n = 168; 35.3%) was the most common place of vaccination followed by doctor's office (n = 147; 30.9%). Fewer than half of cases reported a suspected administration error; 172 (36.1%) reported 'injection too high' on the arm. Shoulder pain, rotator cuff problems, and bursitis were common initial diagnoses. Most (80.0%) cases received physical or occupational therapy, 60.1% had at least one steroid injection, and 32.6% had surgery. Most (71.9%) healthcare providers who gave opinions on causality considered the injury was caused by vaccination. A minority (24.3%) of cases indicated that symptoms had resolved by the last visit available in medical records.

CONCLUSIONS

Most conceded claims for SIRVA were in women and involved influenza vaccines. Injection too high on the arm could be a factor due to the risk of injecting into underlying non-muscular tissues. Healthcare providers should be aware of proper injection technique and anatomical landmarks when administering vaccines.

Reports of atypical shoulder pain and dysfunction following inactivated influenza vaccine, Vaccine Adverse Event Reporting System (VAERS), 2010-2017

BACKGROUND

Vaccines administered into or too close to underlying joint structures have the potential to cause shoulder injuries. Limited data exist on the epidemiology of such events.

OBJECTIVE

To describe case reports of atypical shoulder pain and dysfunction following injection of inactivated influenza vaccine (IIV).

METHODS

We searched the Vaccine Adverse Event Reporting System (VAERS) database from July 2010 to June 2017 for reports of atypical shoulder pain and dysfunction following IIV. When identifying reports, we made no assumptions about true incident injury or causality with respect to vaccination. Pain had to begin <48 h after vaccination and signs and symptoms had to continue for >7 days to differentiate from self-limited local reactions. We conducted descriptive analysis.

RESULTS

We identified 1220 reports that met our case definition (2.0% of all IIV reports, range 1.5%-2.5% across influenza seasons). Median age was 52 years (range 16-94) and most patients (82.6%) were female. Shoulder pain (44.1%), injected limb mobility decreased (40.8%), joint range of motion decreased (21.2%), rotator cuff syndrome (9.2%), and bursitis (9.0%) were frequently reported. In 86.6% of reports, signs and symptoms had not resolved by the time of report submission. In reports that included descriptions suggesting contributing factors (n = 266), vaccination given "too high" on the arm was cited in 81.2%. Nearly half (n = 605, 49.6%) of reports described a healthcare provider evaluation. Treatments included non-narcotic analgesics, physical therapy, and corticosteroid injection. Vaccinations were most commonly administered in a pharmacy or retail store (41.0%) or doctor's office or hospital (31.6%).

CONCLUSIONS

Reports of atypical shoulder pain and dysfunction following IIV were uncommon, considering the amount of IIV use, and stable across influenza seasons. While specific etiology of cases is unknown, improperly administered vaccine, which is preventable, might be a factor. Prevention strategies include education, training, and adherence to best practices for vaccine administration.