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Stone CA, Garvey LH, Nasser S, Lever C, Triggiani M, Parente R, Phillips EJ. Identifying and Managing Those at Risk for Vaccine-Related Allergy and Anaphylaxis. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:2008-2022. [PMID: 37182566 DOI: 10.1016/j.jaip.2023.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 04/13/2023] [Accepted: 05/01/2023] [Indexed: 05/16/2023]
Abstract
Immediate hypersensitivity reactions to vaccines, the most severe of which is anaphylaxis, are uncommon events occurring in fewer than 1 in a million doses administered. These reactions are infrequently immunoglobulin E-mediated. Because they are unlikely to recur, a reaction to a single dose of a vaccine is rarely a contraindication to redosing. This narrative review article contextualizes the recent knowledge we have gained from the coronavirus 2019 (COVID-19) pandemic rollout of the new mRNA platform with the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccines within the much broader context of what is known about immediate reactions to other vaccinations of routine and global importance. We focus on what is known about evidence-based approaches to diagnosis and management and what is new in our understanding of mechanisms of immediate vaccine reactions. Specifically, we review the epidemiology of immediate hypersensitivity vaccine reactions, differential diagnosis for immune-mediated and nonimmune reaction clinical phenotypes, including how to recognize immunization stress-related responses. In addition, we highlight what is known about mechanisms and review the rare but important contribution of excipient allergies and specifically when to consider testing for them as well as other key features that contribute to safe evaluation and management.
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Affiliation(s)
- Cosby A Stone
- Center for Drug Safety and Immunology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn
| | - Lene H Garvey
- Allergy Clinic, Department of Dermatology and Allergy, Copenhagen University Hospital-Herlev and Gentofte, and Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Shuaib Nasser
- Department of Allergy, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Charley Lever
- Department of Allergy, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Massimo Triggiani
- Division of Allergy and Clinical Immunology, University of Salerno, Salerno, Italy
| | - Roberta Parente
- Division of Allergy and Clinical Immunology, University of Salerno, Salerno, Italy
| | - Elizabeth J Phillips
- Department of Dermatology, Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tenn; Department of Pharmacology, Vanderbilt University School of Medicine, Nashville, Tenn; Institute for Immunology & Infectious Diseases, Murdoch University, Murdoch, Perth, Western Australia.
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Influence of dose and frequency of antigen injection on IgE development in young children: a comparison of fire ant stings and tetanus immunizations. Ann Allergy Asthma Immunol 2009; 103:337-41. [PMID: 19852199 DOI: 10.1016/s1081-1206(10)60534-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Previous studies suggest that small antigen doses given frequently are more likely to induce IgE production than are large antigen doses given infrequently. OBJECTIVE To compare the prevalence of antitetanus IgE resulting from the relatively large dose of tetanus toxoid delivered by standard immunizations at 2, 4, 6, and 18 months of age with the previously reported prevalence of anti-fire ant venom IgE resulting from the relatively small dose of venom delivered sporadically by accidental fire ant stings in children younger than 5 years. METHODS This study uses previously published data on the prevalence of IgE antibodies to imported fire ant venom among children living in an imported fire ant endemic area of Georgia and antitetanus IgE measurements of children recruited between August 1, 2003, and December 30, 2007, as part of the Wayne County Health, Environment, Allergy, and Asthma Longitudinal Study in Michigan, where there are no imported fire ants. The prevalence of anti-fire ant venom IgE antibodies was compared with the prevalence of antitetanus IgE antibodies in these 2 cohorts of children. RESULTS The reported prevalence of IgE to fire ant venom among 42 children 2 to 5 years old was 57.1% using a cutoff of 0.1 IU/mL and 35.7% using a cutoff of 0.35 IU/mL. The prevalence of antitetanus IgE in 395 children 2 years old was 52.9% using a cutoff of 0.1 IU/mL and 42.7% using a cutoff of 0.35 IU/mL. The proportion of children with detectable anti-fire ant venom IgE was not statistically significantly different from the proportion of those with antitetanus IgE at either cutoff level (P = .74 and .50 at 0.1 and 0.35 IU/mL, respectively). CONCLUSIONS The relatively large dose of tetanus toxoid delivered 4 times during the first 24 months of life produces detectable tetanus specific IgE antibodies as frequently as the smaller doses of venom delivered sporadically by fire ant stings in young children.
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Nakajima K, Dharmage SC, Carlin JB, Wharton CL, Jenkins MA, Giles GG, Abramson MJ, Haydn Walters E, Hopper JL. Is childhood immunisation associated with atopic disease from age 7 to 32 years? Thorax 2006; 62:270-5. [PMID: 17090571 PMCID: PMC2117158 DOI: 10.1136/thx.2006.062547] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND There is ongoing conjecture over whether childhood immunisation leads to an increased risk of developing atopic diseases. OBJECTIVE To examine associations between childhood immunisation and the risk of atopic disease. METHOD Immunisation histories of 8443 Tasmanian children born in 1961 obtained from school medical records were linked to the Tasmanian Asthma Study. Associations between immunisation status and atopic diseases were examined while adjusting for possible confounders using multiple logistic regression. RESULTS Diphtheria immunisation was weakly associated with an increased risk of asthma by age 7 years (odds ratio (OR) 1.3, 95% confidence interval (CI) 1.1 to 1.7), but there was no evidence of any association for four other vaccinations studied. An increased risk of eczema by age 7 years was associated with immunisation against diphtheria (OR 1.5, 95% CI 1.1 to 2.1), tetanus (OR 1.5, 95% CI, 1.1 to 2.0), pertussis (OR 1.5, 95% CI 1.1 to 1.9) and polio (OR 1.4, 95% CI 1.0 to 1.9) but not small pox. Similar but slightly weaker patterns of association were observed between the risk of food allergies and immunisation against diphtheria (OR 1.5, 95% CI 1.0 to 2.1), pertussis (OR 1.4, 95% CI 1.1 to 1.9), polio (OR 1.4, 95% CI 1.00 to 2.1) and tetanus (OR 1.30 95% CI 0.99 to 1.70), but not with small pox. There was no evidence of associations between immunisation history and hay fever, or incidence of later-onset atopic outcomes. CONCLUSIONS The few effects seen in this study are small and age-dependent, and nearly all our findings support numerous previous studies of no effect of vaccines on asthma. Based on these findings, the fear of their child developing atopic disease should not deter parents from immunising their children, especially when weighed against the benefits.
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Affiliation(s)
- Kazunori Nakajima
- Centre for Molecular, Environmental, Genetic and Analytic Epidemiology, School of Population Health, The University of Melbourne, Level 2, 723 Swanston Street, Carlton, VIC 3053 Australia
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Koppen S, de Groot R, Neijens HJ, Nagelkerke N, van Eden W, Rümke HC. No epidemiological evidence for infant vaccinations to cause allergic disease. Vaccine 2004; 22:3375-85. [PMID: 15308362 DOI: 10.1016/j.vaccine.2004.02.033] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2003] [Accepted: 02/29/2004] [Indexed: 10/26/2022]
Abstract
CONTEXT The prevalence of allergic diseases has increased considerably over the last decades. The hygiene hypothesis has emerged, linking reduced microbial exposure and infections early in life with the development of allergic diseases. Especially some of currently available non-replicating infant vaccines are unlikely to mimic a natural infection-mediated immune response that protects against the development of allergic diseases. Moreover, several studies suggested infant vaccinations to increase the risk of allergic diseases. OBJECTIVE To determine whether infant vaccinations increase the risk of developing allergic disease. DATA SOURCES We searched MEDLINE from 1966 to March 2003 and bibliography lists from retrieved articles, and consulted experts in the field to identify all articles relating vaccination to allergy. STUDY SELECTION AND DATA EXTRACTION We selected epidemiological studies with original data on the correlation between vaccination with diphtheria, pertussis, tetanus (DPT), measles, mumps, rubella (MMR) and Bacillus Calmette-Guérin (BCG) vaccine in infancy and the development of allergic diseases, and assessed their quality and validity. DATA SYNTHESIS Methodological design and quality varied considerably between the studies we reviewed. Many studies did not address possible confounders, such as the presence of lifestyle factors, leaving them prone to bias. The studies that offer the stronger evidence, including the only randomized controlled trial at issue published to date, indicate that the infant vaccinations we investigated do not increase the risk of developing allergic disease. Furthermore, BCG does not seem to reduce the risk of allergies. CONCLUSIONS The reviewed epidemiological evidence indicates that, although possibly not contributing to optimal stimulation of the immune system in infancy, current infant vaccines do not cause allergic diseases.
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Affiliation(s)
- S Koppen
- Vaxinostics, Vaccine Center Erasmus University Rotterdam, C/o Erasmus MC--Sophia Children's Hospital, Secretariat Pediatric Infectious Diseases and Immunology, Room Sp 3533, P.O. Box 2060, 3000 CB Rotterdam, The Netherlands
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Mayorga C, Torres MJ, Corzo JL, Alvarez J, García JAC, Rodríguez CA, Blanca M, Jurado A. Immediate allergy to tetanus toxoid vaccine: determination of immunoglobulin E and immunoglobulin G antibodies to allergenic proteins. Ann Allergy Asthma Immunol 2003; 90:238-43. [PMID: 12602673 DOI: 10.1016/s1081-1206(10)62148-5] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Adverse reactions to tetanus toxoid (TT) vaccine are mostly mild and limited to the injection site. However, immunoglobulin (Ig)E-mediated reactions may occur, and the incidence of anaphylactic responses to TT immunization is 0.001%. When TT induces an allergic reaction, the potential causative agents can be TT antigens, thimerosal or aluminum phosphate. OBJECTIVE We studied four children who developed immediate urticaria after TT vaccine, soon after the reaction and 5 years later. METHODS Skin tests were performed separately with TT vaccine and two vaccine components, thimerosal and aluminum phosphate, and the diagnosis was confirmed by provocation test. IgE and IgG antibodies to TT and their specificities were determined. Sodium dodecyl sulfate-polyacrylamide gel electrophoresis and immunoblotting were performed to characterize the antigenic proteins. RESULTS All four children were immediate skin test-positive to TT, but negative to thimerosal and aluminum phosphate; 3 developed a reaction after intramuscular provocation using increasing doses of TT vaccine; and 1 refused to be tested. All these tests were negative in five controls, all of whom received TT vaccine and developed only local swelling at the site of application 24 hours after vaccine administration. After 5 years the IgG antibodies were still high in all cases and the IgE antibody values fell by 50%. Patients allergic to TT vaccine produced IgE and IgG antibodies, which decreased at different rates but remained for at least 5 years. The pattern of antibody decrease was confirmed by radioallergosorbent test, enzyme-linked immunoadsorbent assay, or immunoblotting assay. IgE and IgG antibodies recognized two proteins derived from TT, of 150 and 50 kDa, corresponding to the intracellular form and to a chain of the extracellular form of the tetanus neurotoxin. CONCLUSIONS In children with immediate allergic reactions to TT vaccine, antibodies may persist for at least 5 years, requiring evaluation by skin and/or in vitro tests before subsequent treatment.
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Affiliation(s)
- Lorne A Babiuk
- Veterinary Infectious Disease Organization Saskatoon, Saskatchewan S7N 5E3, Canada
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Grüber C, Nilsson L, Björkstén B. Do early childhood immunizations influence the development of atopy and do they cause allergic reactions? Pediatr Allergy Immunol 2001; 12:296-311. [PMID: 11846867 DOI: 10.1034/j.1399-3038.2001.1r046.x] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Concerns about allergic side-effects of vaccines and about a possible promotion of allergic diseases contribute to incomplete vaccination rates in childhood. This article reviews the current understanding of these issues. There is evidence that pertussis and diphtheria/tetanus antigens elicit immunoglobulin E (IgE) antibody formation as part of the immune response. In murine models, pertussis toxin is an effective adjuvant for IgE formation against simultaneously administered antigens. In children, however, sensitization to unrelated antigens or development of allergic diseases do not seem to be augmented. In contrast, bacille Calmette-Guérin (BCG) and measles vaccination have been proposed as suppressors of allergy because of their T helper 1 (Th1)-fostering properties. In the murine system, BCG inhibits allergic sensitization and airway hyper-reactivity. Some epidemiological studies in humans suggest an inhibitory effect of tuberculosis on allergy. BCG vaccination in children, however, has no or merely a marginal suppressive effect on atopy. Other vaccine components such as egg proteins, gelatin, and antibiotics are a potential hazard to children with severe clinical reactions to these allergens. These rare children should be vaccinated under special precautions. In conclusion, vaccination programs do not explain the increasing prevalence of allergic diseases, but individual children may uncommonly develop an allergic reaction to a vaccine. The risks of not vaccinating children, however, far outweigh the risk for allergy. Therefore, childhood vaccination remains an essential part of child health programs and should not be withheld, even from children predisposed for allergy.
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Affiliation(s)
- C Grüber
- Department of Pediatric Pneumology and Immunology, Charité - Humboldt University, Berlin, Germany.
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Grüber C, Lau S, Dannemann A, Sommerfeld C, Wahn U, Aalberse RC. Down-regulation of IgE and IgG4 antibodies to tetanus toxoid and diphtheria toxoid by covaccination with cellular Bordetella pertussis vaccine. JOURNAL OF IMMUNOLOGY (BALTIMORE, MD. : 1950) 2001; 167:2411-7. [PMID: 11490032 DOI: 10.4049/jimmunol.167.4.2411] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Pertussis (P) toxin acts as adjuvant for IgE formation against simultaneously administered Ags in animal models. P vaccination may also have an adjuvant impact on IgE formation against coadministered diphtheria (D) and tetanus (T) Ags in humans. Sera of 103 D-T-P-immunized and 319 D-T-immunized children aged 2 years were analyzed for IgE, IgG4, and IgG to D and T (radioallergosorbent test), total IgE and IgE against common inhalant allergens (CAP radioallergosorbent test fluoroenzyme immunoassay). Fewer D-T-P- than D-T-immunized children had sera positive for T-IgE (12.6 vs 53.6%, p < 0.001), T-IgG4 (71.6 vs 89.2%, p < 0.001), D-IgE (31.0 vs 70.5%, p < 0.001), and D-IgG4 (85.2 vs 93.4%, p = 0.039). Suppression of T-IgE was not dependent on the cutoff chosen for a positive test result, but was dependent on the proportion of D-T immunizations given with P. The risk for sensitization to common environmental allergens did not differ (odds ratio 0.953, 95% confidence interval 0.815-1.114). No significant differences between D-T- and D-T-P-immunized children were found with regard to T-IgG or D-IgG. In summary, IgE and IgG4 (but not IgG) serum levels to coadministered D- and T-Ags are suppressed among P-immunized children as compared with nonimmunized children. These results suggest that the presence of a microbial product during Ag exposure can down-regulate an IgE/IgG4 response in humans.
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Affiliation(s)
- C Grüber
- Department of Pediatric Pneumology and Immunology, Charité-Humboldt University, Berlin, Germany.
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Hurwitz EL, Morgenstern H. Immediate and longterm effects of immune stimulation: hypothesis linking the immune response to subsequent physical and psychological wellbeing. Med Hypotheses 2001; 56:620-4. [PMID: 11399109 DOI: 10.1054/mehy.2000.1217] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
We hypothesize that antigenic stimuli in susceptible persons during key developmental life stages alters neuroendocrine-immune organization and leads to the development of aberrant immune and neuroendocrine responses to subsequent environmental stressors, with longterm physical and psychological consequences. The release of interleukin-1beta (IL-1beta) and other proinflammatory cytokines associated with the immune response during times when individuals are most vulnerable to the effects of environmental influences activates the hypothalamic-pituitary-adrenal (HPA) axis and leads to maladaptive responses to subsequent stressors. The primed HPA axis is reactivated by proinflammatory cytokines, resulting in the secretion of corticotropin-releasing hormone (CRH) and cortisol, followed by physical and psychological effects that feedback on the HPA axis to produce an array of outcomes affecting general wellbeing. Through the release of histamine and other mediators and their effects on the mast cell-leukocyte cytokine cascade, immune stimuli in susceptible persons increase allergic inflammation and magnify stressors' effects through the release of HPA-axis-activating cytokines, such as IL-1beta, that drive the axis and reinforce the physiological and behavioral effects. Thus, specific proinflammatory cytokines and allergic reactions initiate, promote, and maintain immune-stimulus-associated HPA axis activity, and with CRH and cortisol, participate in a positive feedback loop, resulting in aberrant, maladaptive responses to physical or psychological stressors, with outcomes such as depression, hyperalgesia, and pain-related behavior.
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Affiliation(s)
- E L Hurwitz
- Department of Epidemiology, UCLA School of Public Health, Los Angeles, California, USA.
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Hurwitz EL, Morgenstern H. Effects of diphtheria-tetanus-pertussis or tetanus vaccination on allergies and allergy-related respiratory symptoms among children and adolescents in the United States. J Manipulative Physiol Ther 2000. [DOI: 10.1016/s0161-4754(00)90072-1] [Citation(s) in RCA: 58] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Abstract
BACKGROUND Pertussis toxin (PT) stimulates IgE production in animals, and pertussis vaccination and whooping cough may have similar effects in man. METHODS We analyzed IgE responses to PT (PT-IgE) in sera from children primarily immunized with three doses of either an acellular 2- or 5-component vaccine, or a whole-cell (Wc) pertussis vaccine, and in children after whooping cough. The study comprised 50 children with both atopic disease and positive skin prick test, 99 nonatopic controls, and 40 children with verified pertussis. RESULTS Immunoglobulin E antibodies against PT were demonstrated in 19% and 24% of sera from vaccinated children at 7 and 12 months, respectively, and in 9% at 2.5 years. At 7 months, PT-IgE was more common after vaccination with acellular (24%) than with the Wc vaccine (3%, P = 0.02). PT-IgE was also more common (P = 0.001) after vaccination in children classified as atopic (36%) than in the control group (10%). Thirty percent of the children with pertussis had PT-IgE, more often so in atopic than nonatopic children (P = 0.02). CONCLUSIONS Transient production of PT-IgE seems to be common after primary pertussis immunization with acellular vaccines, and after whooping cough, particularly in atopic subjects.
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Affiliation(s)
- L Nilsson
- Department of Health and Environment, Linköping University, Sweden
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