Vaccines

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12/17/2021
Question: Could you please clarify the recommendations and considerations surrounding COVID-19 vaccination for individuals with persistently elevated tryptase levels. Early in the vaccination campaign there was conversation surrounding conditions with elevated tryptase and/or mast cell conditions being a vaccine contraindication but more recently I have not seen these recommendations persist.

Our clinic has a patient who has had a persistently elevated tryptase level (generally 23-30) with several episodes of idiopathic anaphylaxis-type episodes. Work up suggests GPA/mast cell activation - consult with hematology suggests mast cell activation secondary to his autoimmune disorder (hx: Wegener's granulomatosis) or due to hypersensitive reaction) considered though bone marrow shows Normocellular (40%) bone marrow with mild nonspecific myeloid hypoplasia and no evidence of increased mast cell population.

Answer: Individuals with mast cell activation syndrome or mastocytosis can be safely vaccinated with any of the approved COVID-19 vaccines and should be vaccinated.

A prophylactic dose of a non-sedating antihistamine prior to vaccination may improve acute tolerability.

https://pubmed.ncbi.nlm.nih.gov/33831618/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8141687/

12/14/2021
Question: A 63-year-old Caucasian female with CVID and postsplenectomy asked me about Evusheld which was recently released by the FDA under EUA. She has had 3 SARS–COV2 vaccinations so she has had her booster vaccination. However, her responsiveness to vaccine such as pneumococcus was nil. Given the fact that in a recent reply on this website it was thought that antibodies to SARS–Cov2 should be in gammaglobulin products due to the 9 month turnaround of production, (or at some point now or soon) what would be your recommendation for immune deficient patients on gammaglobulin? Under what circumstances might this product be offered?

Answer: Romero and coworkers noted that specific anti-SARS-CoV-2 antibodies were first detected in their batches of IVIg products manufactured from plasma collected in the United States in September, 2020, with increased titers observed by October, 2020. They note that with their company, Grifols, there is only about a 4-month lag between plasma collection and the release of a lot of IVIg. https://www.thelancet.com/journals/laninf/article/PIIS1473-3099(21)00059-1/fulltext

Weifenbach and coworkers recently reviewed 14 publications reporting on the outcomes of 68 individuals with CVID who were infected with COVID-19. They noted the number of CVID patients with moderate to severe (~29%) and critical infection courses (~10%), and the number of fatal cases (~13%), appeared to be increased compared to the general picture of COVID-19 infection. They also noted that this might be an overestimate. https://pubmed.ncbi.nlm.nih.gov/33979068/

Many individuals with CVID appear to tolerate infections with COVID fairly well, apparently because they often have effective T-cell mediated immunity despite their inability to produce new protective antibodies. https://pubmed.ncbi.nlm.nih.gov/33424856/

Greenmyer and coworkers at the Mayo Clinic noted in a group of 19 individuals with CVID all patients surviving, 26% (5 of 19) of them were hospitalized and 21% (4 of 19) of the individuals were treated with monoclonal antibodies in the outpatient setting. In 83% (5 of 6) of the patients who were evaluated, post-infection (antinucleocapsid) seroconversion was reported. After recovering from their COVID-19 infection, 32% (6 of 19) of the patients were vaccinated against SARS-CoV-2 infection, which they tolerated well, with no significant adverse events reported. Post-immunization anti-spike serology was positive in the 1 individual in whom it was performed. Greenmyer J, Joshi A. COVID-19 in CVID: a large hospital experience. Ann Allergy Asthma Immunol. 2021;127:S3-S17:Abstract A044. Presented at: American College of Allergy, Asthma & Immunology (ACAAI) 2021 Annual Scientific Meeting; November 4-8, 2021; New Orleans, Louisiana.

Tixagevimab co-packaged with cilgavimab has an emergency use approval for individuals with moderate to severely compromised immune systems due to a medical condition or due to taking immunosuppressive medications or treatments and may not mount an adequate immune response to COVID-19 vaccination. Thus an individual with CVID and/or splenectomy would meet the criteria for this emergency use approval. https://www.fda.gov/media/154701/download

12/3/2021
Question: Reactions to mRNA vaccines have brought patients in who are vaccine hesitant due to systemic reactions after colonoscopy prep with Miralax. In reviewing the literature, it seems skin testing for IgE mediated PEG allergy may result in false negative using available Medrol solutions with and without PEG. Therefore a negative result would seem to require a challenge. I cannot find a challenge protocol that has been published. Can you provide one? The alternative is, of course, to use a bowel prep that does not contain PEG.

Answer: Polyethylene glycol allergy testing should only be done in individuals with acute onset itching, hives, and/or anaphylaxis within 1 hour of systemic exposure to polyethylene glycol. We currently use the following protocol:

Use Miralax dilutions for prick skin testing. Do not do any intradermal skin testing.

• Step 1: Miralax 1:100 (1.7 mg/ml)

• Step 2: Miralax 1:10 (17 mg/ml)

• Step 3: Miralax 1:1 (170 mg/ml)

A positive skin test results is a wheal at least 5 mm with flare greater than wheal. If all negative, then oral challenge with Miralax 85 mg (0.5 ml mixed in 10 ml of water) and observe for 1 hour.
 

References:

J Allergy Clin Immunol Pract. 2021;9:1765-66.

J Allergy Clin Immunol Pract. 2021;9:1423-37.

J Allergy Clin Immunol Pract. 2021;9:670-5.

12/2/2021
Question: If someone had a recent reaction to Bactrim with a rash, fever and neck pain how long after this reaction can a COVID-19 booster be given? After 2 weeks our patient feels fine. Rash resolved.

Answer: A benign delayed onset rash after the use of trimethoprim sulfamethoxazole, that has now completely resolved, is not a contraindication to receiving any COVID-19 booster immunization. The risk of acquiring COVID-19 dramatically outweighs any minimally increase vaccine-related risk. Having any drug intolerance slightly increases the chance of having an adverse reaction associated with any future drug or vaccine administration.

12/2/2021
Question: One of our NICU nurses had severe facial paralysis 10 days after the first COVID-19 dose (Pfizer) in February 2020. The neurologist agreed, at the end of diagnostic path, that it was a vaccine adverse event, and got her, to work, a temporary exemption certificate for the following doses until complete resolution. Now she's better, and our hospital health department has decided to move her to administrative duties since she's not fully vaccinated. They say that she could be a threat to patients (even though she's willing to get a COVID-19 test every 2-3 days) and she's at risk of COVID-19 disease (she works now in healthy newborn nursery). Still, no one (the immunologist, the infectivologist, the occupational doctor) has released to her a clear proof of adverse reactions or a simple statement that it's unsafe for her to be vaccinated. She's sad because she really loves her work, and this shift would be a clear demotion both professionally and economically. Is there any study on this correlation (COVID-19 vaccine and facial paralysis)? Is she eligible for a new vaccination session with a different vaccine?

Answer: In a case-control study of 37 patients with acute-onset facial nerve palsy and a matched control group, no increased risk of facial nerve palsy was observed after Pfizer-BioNTech BNT162b2 COVID-19 vaccination.

In addition, no meaningful increase in the number of admissions for facial nerve palsy was observed compared with preceding years. These outcomes suggest that recent vaccination with the BNT162b2 vaccine is not associated with an increased risk of facial nerve palsy. https://jamanetwork.com/journals/jamaotolaryngology/fullarticle/2781367

It would be OK for this individual to get any additional vaccine doses needed to be protected as well as possible from COVID-19.

11/8/2021
Question: A 59-year-old female with medical history of hypothyroidism, celiac disease, osteopenia, and obstructive sleep apnea was referred to my office to discuss an adverse reaction to the second dose of the Pfizer COVID-19 mRNA vaccine. There is a history of an adverse reaction to the shingles and tetanus vaccines.

She received her first dose of the Pfizer vaccine and reported local arm soreness. She developed symptoms of a distal rash from the injection site approximately one day after her second dose of the Pfizer vaccine. Associated symptoms included fever, lymphadenopathy, and fatigue. The rash was progressive and eventually developed into a diffuse maculopapular rash that peaked 48 hours after injection. The fever resolved in 24 hours. The lymphadenopathy and rash resolved within one week.

She had a similar reaction to the second dose of the shingles vaccine. She developed a distal rash one day after her initial injection. She pretreated with Benadryl one hour before her second shingles injection, and she developed a delayed rash, fever, and lymphadenopathy that eventually resolved with the week.

She developed what sounds like an Arthus reaction to the tetanus vaccine in childhood. She followed a split dosing regimen in childhood, and she has eventually been able to tolerate the tetanus and pertussis vaccine without reaction in adulthood.

We discussed that the presentation sounds more consistent with a serum sickness-like reaction versus an IgE mediated allergic reaction.

She would like to receive a booster vaccine. What is the best recommendation regarding a booster vaccine? Strict avoidance? Consideration for switching to the Johnson & Johnson vaccine? Consideration for the Pfizer or Moderna vaccinations with a premedication plan? If so, what premedication plan may be considered for a serum sickness-like reaction?

Answer: I am sorry to tell you that there is no best recommendation. Unless your patient's maculopapular rash progressed to Stevens Johnson Syndrome or involved the mucosa, and since the reaction clearly was not anaphylactic, such a reaction is not an absolute contraindication to subsequent vaccination. Premedication with antihistamine or steroids in this setting is not likely to be helpful. It is reassuring that the constellation of symptoms appears to have been self-limited during the prior episodes. There is no data on which to base a decision about administering an alternative vaccine and I think it is unlikely that this approach would have a different outcome since your patient has reacted to non-COVID-19 vaccines in a similar manner. If your patient decides to pursue a booster dose, I think supportive care for symptom management with acetaminophen or NSAIDs could be considered.

Here is a link to the CDC guidance https://www.cdc.gov/vaccines/covid-19/clinical-considerations/covid-19-vaccines-us.html#Appendix-B.

Question: A 35-year-old female developed signs/symptoms consistent with anaphylaxis (urticaria, angioedema, near syncope, dyspnea, and wheezing on exam) within minutes of receiving the Janssen COVID-19 vaccine. The patient immediately received an epinephrine injection and was sent to the ED for monitoring. The patient has not received an influenza vaccine in years. Now the patient is hesitant to have an influenza vaccine administered. Given the history of anaphylaxis to the Janssen COVID-19 vaccine, the primary provider is requesting guidance on the influenza vaccine and guidance/recommendations on future booster COVID-19 vaccines if/when recommendations are made for other COVID-19 vaccines (currently only recommendations for booster injections are made for the Pfizer-BioNTech COVID-19 vaccine.)

Answer: There is no evidence of cross reactivity between any of the COVID-19 vaccines and the flu shot. As such, there is no reason to presume a priori that he/she will have a reaction to the seasonal flu shot. (Reference 1) The CDC has offered guidelines on the management of these patients (Reference 2). If the patient opts to receives a booster, then one should consider one of the mRNA vaccines. A thorough discussion of the risk and benefits of the booster and using a different vaccine should be discussed with the patient and a mutually agreed upon plan should be developed.

In terms of risk for the flu vaccine in the future, I think the risk would be very low and should be considered. If the patient is concerned one could consider a skin test with the flu vaccine and make further decisions based upon the skin test results.

Question: I have a 61-year-old patient, previously healthy, who received the first dose of Pfizer mRNA COVID-19 vaccine in June 2021. Within 10 minutes, he developed paraesthesia in the left side of the face, neck and arm, and hives on the shoulder the same side as he received the vaccine. He was taken to the emergency department and had a CT scan of the head and some blood work, but nothing suspicious was found. He also had some loose stool for the first one or two days after the vaccination. The paraesthesia gradually improved. However, he gained his full recovery about two weeks ago. This patient is very keen to receive the second dose of his vaccine and is not anti-vaccine at all. Of note, this case is in Canada and only Pfizer and Moderna are available. I would greatly appreciate your advice about safety of receiving his second dose.

Answer: Rarely "complications" after vaccination have uncovered significant other medical issues unrelated to the vaccine but it appears that this is not the case in this patent (Reference 1). Interestingly (Reference 2) functional neurologic disorder can occurred after vaccination. In a patient who has had neurologic symptoms after a vaccine, consultation with a neurologist would be helpful to understand if there is any pathology that could explain the patient’s symptoms. Assuming there is no pathology, then a discussion with the patient about their risk from a second dose and their risk of becoming infected with COVID-19 and possible complications need to be had in order to come to a shared decision about whether to proceed with a second dose.

10/26/2021
Question: A 25-year-old female RN, has a history of having an immediate anaphylactic reaction after getting flu vaccine in doctor's office requiring epinephrine in early 2000's. She has not taken any vaccine after that. Couple of years before that she had MMR vaccine following which she was very sick with fever and chills. Two days later she could not walk. It took her several weeks to recover and she still has chronic fatigue since then. She was tested positive for PEG and Polysorbate in Washington, DC. (No record available) She has known allergy to metals like nickel, silver, and toothpaste. Toothpaste caused her irritation of the tongue and gums. She uses homemade toothpaste. She has never taken Miralax and never had colonoscopy. According to her she has multiple food and inhalant allergies. There are no records available to verify her history. In view of the above history, can she take the COVID-19 vaccine?

Answer: Thank you for your question. A prior history of reaction to flu vaccine does not preclude getting the COVID-19 vaccines that are available in the United States. Her reaction to the MMR vaccine was not IgE mediated. Metal allergy, food allergy and inhalant allergy are not contraindication for the COVID-19 vaccine. She reports h/o +ve testing PEG and polysorbate but no records are available. I do not think any of these would disqualify her from receiving the COVID-19 vaccine. Overall, I think that she would be at greater risk complication for getting COVID-19 than from getting the COVID-19 vaccine. One option I do suggest to patient like these, and this is just my opinion, is to consider a 1/10th test dose, monitor for 30 minutes and if the patient is stable then a full dose can be administered.

10/7/2021
Question: I have a patient who had pericarditis to the influenza vaccine in 1996 and who wants to get the COVID-19 vaccine. Her PCP has advised her to not get the COVID-19 vaccine but she is eager to have protection against COVID-19. Is there any contraindication to getting the COVID-19 vaccine or can she receive it?

Answer: Pericarditis after flu vaccination is very rare (https://www.ncbi.nlm.nih.gov/labs/pmc/articles/PMC5935955/). There is a suggestion in the literature that these patients may be at risk for recurrence of pericarditis from the flu vaccine. The challenge here is that COVID-19 infection can cause myocarditis / pericarditis but it is not clear that having previous pericarditis places the patient at increased risk.

There are no data suggesting a history of pericarditis from influenza vaccine increases the risk of this reaction from an mRNA COVID-19 vaccine. In fact, the risk of pericarditis from the J&J adenovirus vaccine is much less (https://jamanetwork.com/journals/jama/fullarticle/2782900) and it may be worthwhile discussing this risk with the patient and vaccinating with the J&J vaccine, if she agrees with the low risk.

In general, I would say the risk of myocarditis / pericarditis is greater from COVID-19 infection than the COVID-19 vaccination. In this case, however, I would seek the opinion of cardiology.

10/5/2021
Question: I have a 37-year-old female who has concerns with COVID-19 vaccine. She had COVID-19 infection July 2020. Had symptoms of low-grade fever four to five days, tightness in chest, slight cough, fatigue. No long term COVID-19 symptoms. She had Pfizer COVID-19 vaccine on 8/5/21. Later that day, she had HA, dizziness and nausea which lasted a few days and then resolved. Later that week experienced left side body weakness and numbness for three days, then resolved. Saw PMD 8/10/21 and echo, blood work was normal. Symptoms resolved.

A few weeks later, she had another episode of dizziness. Saw PMD on 8/19/21. Had left side weakness that resolved after one to two days. Mild chest pressure and tightness in chest. Nausea and dizziness lasted three weeks. At time of visit with me on 9/14/21 symptoms had resolved. She is questioning whether or not she should receive a second dose of vaccine, trying to weigh risk vs benefit in light of having infection in past and one vaccine. I tried to perform research on this and couldn't find much on the weakness and numbness symptoms. She is open to getting the vaccine if benefit outweighs risks. Any advice would be appreciated.

Answer: The crux of your question is in a patient who has had COVID-19 and received one dose of the COVID-19 vaccine can / should they get the second dose. This case is complicated by the fact that they appear to have had some constitutional symptoms after the first dose of the COVID-19 vaccine that do not appear to have been IgE mediated. The current answer according to the CDC would be that the patient should get the second dose of the vaccine. In this case, I think shared decision making process should be engaged in order to help the patient make the best decision.

9/28/2021
Question: A 30-year-old male presented with chronic urticaria, that started within 24 hours of the first dose of Pfizer vaccine in March. There was associated intermittent lip swelling for weeks. Never had urticaria in the past. Urticaria persisted daily, was treated with Allegra 180mg two tablets in the morning, Clarinex 5 mg two tablets at bedtime, Pepcid 20mg daily, and montelukast 10mg daily. Urticaria became severe enough that the patient received one short course of prednisone. Labs showed normal CBC, comprehensive metabolic panel, normal, TSH and ANA 1:80. Urticaria persisted and resolved spontaneously in four months. The patient is concerned about receiving second dose of the Pfizer vaccine and worried that the second dose of the Pfizer vaccine will trigger the reoccurrence of chronic urticaria. Is it safe for the patient to receive the second dose of the Pfizer vaccine? Should I advise Janssen vaccine?

Answer: Both acute and chronic urticaria have been noted in case reports after COVID-19 vaccinations and COVID-19 infections. Population-based data is lacking.

The risk of acquiring a COVID-19 infection and suffering from the associated morbidity is likely significantly greater than any potential morbidity associated with a reactivation of chronic urticaria after a booster dose, though these risks are impossible to quantify accurately at this time. Also, the risk of reactivating chronic urticaria with a COVID-19 infection is probably greater than the risk of reactivating chronic urticaria after a booster vaccine dose. The risk is probably not directly related to the exact vaccine used, but from general immune stimulation.

I would recommend boosting with whatever vaccine is available and treating a recurrence of the chronic urticaria (if it occurs) with cetirizine up to 40 mg a day and if needed a course of omalizumab.

9/24/2021
Question: Is it safe for a patient with multiple allergies (including environmental, food, medications & vaccines) to receive any of the COVID-19 vaccines? She developed cough, SOB & hives with an unrecalled vaccine when she was younger. Last year, she had hives with flu vaccine. She had rashes after intake of Miralax. Moreover, she has had other allergic reactions with unknown triggers. She needs advice since her job is requiring her to be vaccinated. She is scared that she would develop a severe allergic reaction to the COVID-19 vaccine or to allergy testing to vaccine & its components.

Answer: It is important that your patient get vaccinated against COVID-19. It would be OK for her to get the Janssen/Johnson & Johnson vaccine and be observed for 30 minutes after the vaccination. If she has not had confirmed anaphylaxis associated with ingestion of polyethylene glycol, then it would also be OK for her to get any of the mRNA vaccines and be observed for 30 minutes after the vaccination.

Sources:

• https://www.cdc.gov/coronavirus/2019-ncov/vaccines/recommendations/specific-groups/allergies.html#:~:text=CDC%20recommends%20that%20people%20get,%2C%20environmental%2C%20or%20latex%20allergies.
• https://www.jaci-inpractice.org/article/S2213-2198(21)00675-9/fulltext
• https://www.jaci-inpractice.org/article/S2213-2198(21)00713-3/fulltext

Question: A 30-year-old male patient asked whether or not he could safely have a COVID-19 vaccine, given his history of anaphylaxis after a flu shot that was a Fluzone brand vaccine out of a multi-dose vial. The ingredients of the fluzone vaccine from that time, per pkg insert, were: Thimerosal, Gelatin, Formaldehyde, octylphenol ethoxylate, Sodium phosphate-buffered isotonic sodium chloride solution, and split influenza virus inactivated strains propagated in embryonated chicken eggs. He is atopic with allergic rhinitis but has no food allergies, and was never evaluated for this possible reaction, rather he has just avoided vaccines since 2014. I plan to evaluate him for allergy to some of the components of the Fluzone, but most of these are not contained in the COVID-19 vaccine preparations currently available.

I'm comparing this with the ingredients of the COVID-19 vaccines (which obviously are very different). I'm wondering if any of the following "nanolipids" PFIZER: (Nanolipid components in the Pfizer-BioNTech vaccine include: ((4-hydroxybutyl)azanediyl)bis(hexane-6,1- diyl)bis(2-hexyldecanoate), 2 [(polyethylene glycol)-2000]- N,N-ditetradecylacetamide, 1,2-distearoyl-sn-glycero-3- phosphocholine) or MODERNA: lipids (SM-102, polyethylene glycol [PEG] 2000 dimyristoyl glycerol [DMG], cholesterol, and 1,2-distearoyl-sn-glycero-3-phosphocholine [DSPC]), tromethamine, tromethamine hydrochloride are related to the Octylphenol Ethoxylate in the Fluzone vaccine?

Any help you could provide on the possibility of a relationship between these molecules would be much appreciated.

Answer: It is OK to administer any mRNA COVID-19 vaccine to an individual with a history of anaphylaxis to a flu vaccine. The nano-lipids in the Pfizer-BioNTech vaccine are immunologically unrelated to octylphenol ethoxylate, which is essentially a detergent.

https://www.jaci-inpractice.org/article/S2213-2198(21)00675-9/fulltext

9/20/2021
Question: Urticarial bullous pemphigoid after Pfizer dose #1 in a patient with a chronic idiopathic pericarditis on anakinra. A 72-year-old male physician developed a diffuse maculopapular dermatitis four days after Pfizer COVID-19 vaccine. Initial biopsy: urticarial bullous pemphigoid. Antiskin antibodies (BP 180) negative. Subsequent biopsies: Negative immunofluorescence - spongiotic dermatitis.

Required prednisone taper. Currently, seven months later, the patient has persistent recurrent urticaria treated with xyzal and doxepin.

Academic dermatologist and allergist #1 recommended no further Pfizer vaccination based on positive COVID-19 serology. Dermatologist recommended considering Janssen vaccine.

Although the benefits of Pfizer dose number two may outweigh the risks with respect to the bullous pemphigoid reaction, does the additional chronic pericarditis diagnosis sway you to substitute Janssen for dose number 2? Or can he receive Pfizer number two as recommended by a recent article on the subject?

"Given the risks of SARS-CoV-2 infection, the rarity of these events, and the uncertainty of causality, clinicians should encourage full vaccination, including completion in those with blisters after the first dose. Our experience suggests that the natural history of SARS-CoV-2 mRNA vaccine–associated BP-like disease may differ from that of conventional BP in some individuals, but further studies are required to confirm this hypothesis.”

Subepidermal blistering eruptions, including bullous pemphigoid, following COVID-19 vaccination Tomayko, Mary M. et al. Journal of Allergy and Clinical Immunology, Volume 148, Issue 3, 750 – 751

Answer: I would recommend a trial of omalizumab for the chronic urticaria, continue on cetirizine 40 mg day, and discontinue the doxepin, given the patients age.

Given the two other, completely different and apparently unrelated, dermatologic manifestations, one typically antibody mediated and one T-cell mediated, associated with the initial Pfizer mRNA immunization, in this patient with an underlying autoimmune pericarditis, I would also recommend considering the Janssen (J&J) vaccine as the booster dose.

9/9/2021
Question: I have a 69-year-old patient who developed a rash on her left arm and face lasting five weeks. This occurred two days after the Moderna RNA vaccine. She got the booster and in less than 24 hours had a more severe rash also on left arm and face lasting several months. When a third shot is available do I tell her to forego a second booster or get it with antihistamine pre-treatment or get a dose of the J&J vaccine?

Answer: These delayed onset benign rashes are thought to be secondary to T-cell activation. They often require no therapy, but if are itchy, treatment with a non-sedating antihistamine may be helpful. They may or may not recur with booster doses and there is no data on their frequency with three doses. If possible, avoid the use of systemic steroids, because this may blunt producing good anti-COVID-19 T-cell immunity. The use of another vaccine such as the J&J is a reasonable choice for a booster dose in this setting. However, there are no data to say that she won’t have a reaction to the J&J vaccine, as well (since this is a presumed T cell response).

1. https://www.nejm.org/doi/full/10.1056/NEJMc2102131
2. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8244618/

9/9/2021
Question: A 49-year-old female who self-referred for flushing and possible food allergy or histamine intolerance. She was found to have a Tryptase of 20 and then 27 on repeat. Gene By gene testing revealed Alpha Tryptase of 4 and Beta Tryptase of 2. She has no Ckit mutation in the blood and has bone marrow biopsy report pending. Interestingly she also has some features of autoinflammation and genetic panel reviewed two variants: MEFV p.Lys695Arg and NOD2 p.Asp154Asn. I have referred her to autoinflammatory disease center for evaluation of this and this is also pending.

She is avidly against the COVID-19 vaccine and she is a pediatric nurse in the hospital. I am aware of other publications of patients with systemic mastocytosis who have been pre-medicated and given the vaccine. I am wondering how you would approach this in a patient with possible HAT and possible autoinflammatory disease. She had the following reaction to Tetanus vaccine: "Experienced severe swelling, redness, and increasing pain radiating to my whole upper left extremity between Day one and three after vaccination. The skin crusted into a weeping scabby area at the vaccine site. I became lethargic and febrile >104° so my husband took me to the ER three days after the vaccine where they administered Benadryl and IV fluids to stabilize me, kept me for an observation period, and advised I do not get the vaccine anymore."

Her mother had a similar reaction to influenza vaccine and her grandmother had similar reaction to tetanus vaccine. Her mother was advised not to get the COVID-19 vaccine by her physician. 

She has never had an allergic reaction to anything with PEG/polysorbate that she is aware of.

I recommended that she should pre-medicate and plan accordingly to feel unwell after the vaccine given her risk of exposure and her risk to her patients.

Answer: I fully concur with your recommendation that she should pre-medicate and plan accordingly to feel unwell after the vaccine given her risk of exposure and her risk to her patients.

1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8019658/

9/10/2021
Question: I saw a 40-year-old male who was referred for evaluation of safety to receive a COVID-19 vaccine. His he is c/w a believed reaction two to three days after receiving H1N1 vaccine more than five years ago. Several days after this vaccine he noted yellow spots all over body and subsequent respiratory distress, intubation and extremity vascular disease requiring partial upper digit amputation. He previously tolerated flu vaccine. Autoimmune hemolysis? How would you handle this in terms of receiving COVID-19 vaccine or any vaccine for that matter?

Answer: Given that the event was more than five years ago and has not recurred since, I believe that a clinically useful work-up of this event at this time, other than an extensive review of data produced nearer to the time of the event, is not possible.

A reaction like this to a previous vaccination is not a contraindication to any of the COVID-19 vaccines currently available, or any other vaccine. Given that each flu vaccine is significantly different, and the implicated flu vaccine was from more than 5 years ago, I would consider this not to be a contraindication to receiving a flu vaccine this year.

This is one of those cases where shared decision making is essential.

9/13/2021
Question: A 61-year-old female patient received first dose of Moderna vaccine on 3/4/21. She stayed for 30 minutes after the shot, felt tired but left to go home. On the way she felt very tired and weak. Her breathing was slow. Her husband had to help her out of the car into the house. Then she started laughing uncontrollably and had difficulty in breathing & talking. She became very incoherent. Irrelevant words came out of her mouth in response to her families' questions, even though she said she understood the questions. Finally, she went to sleep for a few hours and woke up fine that day.

Next day she felt very cold and had severe chills for about 20 minutes and extreme fatigue. The following day she felt normal. In the past she had three adverse reactions after receiving pain killers. First, at age 20, she had her wisdom tooth pulled under LA. She fell asleep in the chair and could not be woken up. She had to be carried to her car and slept for a few hours at home, and then recovered.

Second, at age 34 she was given an Epidural with Suffenta? (Fentanyl related), during labor. Within five minutes her eyes closed shut, she could not swallow and lost consciousness. She was treated and recovered consciousness in 45 minutes and baby was delivered normally.

Third episode was a few years ago, when she went to the ER for severe nosebleed. They put a balloon up her nose and gave pain killer Oxycontin. She came home and started feeling tired, weird, disoriented, and felt something bad was happening to her. After about an hour she started feeling better.

She has no known history of an adverse reaction to any vaccination. She had COVID-19 in 2020 and was sick at home for two and a half months. Can she safely take shingle and flu vaccines? Can she safely take the second COVID-19 dose? What is the relationship, if any, between the reactions to COVID-19 vaccine and pain killers?

Answer: She can safely get any herpes zoster or influenza vaccines needed. She can get the second COVID-19 mRNA vaccine dose and be observed for 30 minutes after the vaccination.

Individuals with multiple drug intolerances appear to be more likely to have benign, often subjective, adverse reactions associated with COVID-19 mRNA vaccinations.

9/13/2021
Question: A 42-year-old female had her first Pfizer COVID-19 vaccine on 6/30/21. She felt dizzy and hot within five minutes, was observed there for 30 minutes and allowed to leave. While at home 40 minutes after the shot, she developed hives. She took Benadryl & Zyrtec and recovered completely in 24 hrs. She has no known history of adverse reactions to any vaccine in the past. She went for second COVID-19 dose on 7/22/21. Within five minutes, she was dizzy, had swelling of lips & face, and shortness of breath. She was treated with IV fluids, Benadryl, and steroids. She was observed for a few hours and then discharged on a Medrol pack. It took her a full week to recover completely.

Can she be safely skin tested for PEG/Polysorbate 20 & 80? Should she avoid taking vaccines containing PEG/Polysorbate 20 or 80? Should she avoid taking medications containing PEG, like Miralax, GoLite laxative, or any other PEG containing medicines that you can list?

Answer: Given the history provided, a clinically significant IgE-mediated allergy to polyethylene glycol and/or any polysorbate is extremely unlikely. If the patient does not have a clinical history of recurrent urticaria associated with polyethylene glycol containing foods or medications, then skin testing and/or an oral challenge to confirm current polyethylene glycol hypersensitivity is not warranted. True IgE-mediated polyethylene glycol is extremely rare.

Systemic corticosteroids are typically not helpful in treating acute urticarial episodes and may suppress development of good anti-COVID-19 T-cell mediated immunity. I would recommend only using cetirizine 10 to 40 mg a day if any future acute urticarial episodes.

9/7/2021
Question: I have now have three patients who have a history of Influenza vaccination "anaphylaxis," with the more recent a clearly severe anaphylactic reaction three years ago. The specific influenza vaccine name unknown in each case. These patients request COVID-19 vaccination recommendations. Is COVID-19 vaccination for skin testing readily available and what would you recommend? We are going to get this question more frequently as we enter the flu season and vaccination.

Answer: There is no population-based data available that show a there is clinically significantly increased rate of anaphylaxis to any vaccination in individuals with a history of confirmed anaphylaxis to any other specific vaccine. What is well known that vaccine-associated anaphylaxis is extremely rare, on the order of 1 in 1,000,000 administrations. In general, the risk of avoiding vaccination is much larger than the risk of morbidity from vaccine-associated anaphylaxis, if an individual is being observed by a physician, or other health care provider, able to treat anaphylaxis.

It is reasonable for individuals with a history of influenza vaccine-associated anaphylaxis to undergo skin testing with the next year's influenza vaccine prior to graded administration with one hour of observation after the last dose, if skin test positive, or full dose administration and one hour of observation, if skin test negative.

Individuals with other specific vaccine-associated anaphylaxis event can be managed in similar fashion if the same exact vaccine is needed for booster immunization.

• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5026780/pdf/40413_2016_Article_120.pdf
• https://www.jacionline.org/article/S0091-6749(17)32922-6/pdf

There is currently no role for skin testing of any kind with mRNA COVID-19 vaccines.

• https://www.jaci-inpractice.org/article/S2213-2198(21)00713-3/fulltext

If there is still concern about intolerance to a mRNA COVID-19 vaccine, then administer a recombinant replication-incompetent Ad26 vector COVID-19 vaccine.

8/30/2021
Question: I have a 13-year-old patient who had generalized urticaria and mild shortness of breath 40 minutes after the first Pfizer dose. Patient took antihistamines and albuterol and did not require ED visit. She is not eligible for other vaccines given age. She had a +spike IgG. Since second dose not given, her school considers her not fully vaccinated. When others at school expose her, school would require quarantine and testing. We don't have access to vaccine to give it in the clinic with AH pretreatment. Parents nervous about giving vaccine at a retail drug store. What are your recommendations?

Answer: In a large study, conducted at Sheba Medical Center in Israel, 8102 patients with allergies applied to the COVID 19 vaccine referral center and underwent risk assessment, using an algorithm that included a detailed questionnaire. Of these, high-risk patients (n = 429) were considered “highly allergic” and were immunized under medical supervision. The rate of allergic reactions to BNT162b2 vaccine, was found to be higher among patients with allergies (1.4%), particularly among a subgroup with a history of high-risk allergies. The authors concluded that administration of the mRNA vaccine is best done in a setting for immunization under medical supervision for highly allergic patients. (1)

In a study by Wolfson et al. (2), 80 individuals who reported allergic reactions after the first dose of mRNA vaccines, excipient skin testing to PEG and/or polysorbate 80 did not impact tolerance of the second dose in those with positive skin tests. 70 out of the 80 received their second dose, 62 had either no reaction or a mild reaction managed by antihistamines, although two did require epinephrine. This small study supports that the majority patients with an immediate, non-anaphylactic, allergic reaction following first mRNA vaccine can proceed with 2nd dose safely. The authors propose an interesting algorithm regarding how to proceed.

Using shared decision-making, most individuals with immediate reactions to the first dose of an mRNA COVID-19 vaccine can proceed safely with the second dose.

If concerned about an allergy to PEG, you may consider testing for this excipient. Even without a prior history, though rare, there have been reports of development of allergy to PEG on first exposure. There are recent publications addressing approaches to evaluation for potential PEG allergy. (1,3)

Since you do not have access to the vaccine, I suspect your patient’s pediatric or family practice office offers the vaccine and would provide an opportunity for supervised administration and at least a 30-minute observation period.

1. Wolfson AR, Robinson LB, Li L, et al. First-Dose mRNA COVID-19 Vaccine Allergic Reactions: Limited Role for Excipient Skin Testing. J Allergy Clin Immunol Pract. 2021;S2213-2198.
2. Shavit R, Maoz-Segal R, Iancovici-Kidon M, et al. Prevalence of Allergic Reactions After Pfizer-BioNTech COVID-19 Vaccination Among Adults with High Allergy Risk. JAMA Netw Open. 2021 Aug 2;4(8):e2122255. doi: 10.1001/jamanetworkopen.2021.22255. PMID: 34463744.
3. Sellaturay P, Nasser S, Ewan P. Polyethylene Glycol-Induced Systemic Allergic Reactions (Anaphylaxis). J Allergy Clin Immunol Pract. 2021 Feb;9(2):670-675.

8/18/2021
Question: I work at a private allergy office and we are trying to figure out what to recommend for our specific antibody deficient patients and whether or not they should be getting a booster vaccine based off of the CDC's new guidelines for immunocompromised people. I'm not sure if there's any research regarding this specific population or if there's consensus in regards to this.

Answer: The purpose of the third vaccine is to address those that had sub-optimal response to the initial series. The CDC has stated those with moderate to severe primary immunodeficiency (PIDD) should receive the booster. In my opinion, other than IgA deficiency, all patients with PIDD should be considered eligible for a third vaccine.

To my knowledge, there are no data regarding criteria for third dose in primary immunodeficiency. In fact, there are limited data specifically addressing COVID-19 vaccine response in patients with primary immunodeficiency. The NIH is conducting a large study of 400 patients with primary immunodeficiency addressing response to COVID-19 vaccine, the results of which are pending and may address your question best. Though outside the scope of your question, I have summarized the limited data that are available at this time.

Three small studies addressing the effectiveness of the mRNA COVID-19 vaccine, focusing on CVID, have been published (1, 2, 3). Most recently, Romano et. al (1), was released pre-publication in Annals of Allergy, Asthma, and Immunology (link below). This study looked at 5 CVID patients, one had had a natural infection and the remaining 4 had no detectable anti–SARS-CoV-2 antibodies before vaccination. Each patient was vaccinated with the Pfizer-BioNTech mRNA vaccine.

Postvaccination, all patients but 1 developed neutralizing antibodies against SARS-CoV-2. The patient who failed to have a substantial rise in postvaccination titers of anti–SARS-CoV-2 antibodies also had a marked decrease in the frequency of circulating B cells. They concluded that SARS-CoV-2 vaccination is safe and effective even in patients with primary antibody deficiencies. Two additional studies (2,3), reported on 6 patients and 13 patients respectively, likewise demonstrated that patients were able to mount specific antibody responses after vaccination. However, patients with absence of B cells (ie, patients with X-linked agammaglobulinemia) failed to have production of neutralizing antibodies against SARS-CoV-2. These patients did produce robust antiviral cellular responses, which still may justify vaccination.

Although the data are limited, these small studies support mRNA COVID-19 vaccination in primary immunodeficiency, with regards to safety and production of neutralizing antibodies.

References

1. Romano C, Esposito S, Donnarumma G, Marrone A. Detection of neutralizing anti-severe acute respiratory syndrome coronavirus 2 antibodies in patients with common variable immunodeficiency after immunization with messenger RNA vaccines. Ann Allergy Asthma Immunol. 2021 Aug 2:S1081-1206(21)00523-8. doi: 10.1016/j.anai.2021.07.026. Epub ahead of print. PMID: 34352358; PMCID: PMC8327608. In Press
2. Squire J, Joshi A. Seroconversion after coronavirus disease 2019 vaccination in patients with immune deficiency [e-pub ahead of print]. Ann Allergy Asthma Immunol. doi:10.1016/j.anai.2021.05.015, accessed June 12, 2021.
3. Hagin D, Freund T, Navon M, et al. Immunogenicity of Pfizer-BioNTech COVID-19 vaccine in patients with inborn errors of immunity [e-pub ahead of print]. J Allergy Clin Immunol. doi:10.1016/j.jaci.2021.05.029, accessed June 12, 2021.

8/22/2021
Question: Does anyone know how long it might take for COVID-19 anti-spike antibodies to get into the immunoglobulin supply for patients being treated for hypogammaglobulinemia? I realize that it might take quite a while, but I'm not really sure how long, and I haven't gotten a return call from the couple of companies I've called. I really don't check antibody levels but I decided to go ahead with it in one of my SIgG deficiency patients who'd been vaccinated and her #'s were great. As I know that her T-cells generally work I'd like to be able to tell whether what she has was actually made by her.

Answer: The time from acquisition of donor serum to final product takes approximately nine months. Administration of SARS-CoV-2 vaccines began mid-December 2020, eight months ago. We saw our first case of COVID-19 in the U.S. in January 2020, twenty months ago. It is almost certain there would be measurable SARS-CoV-2 antibody in current immunoglobulin product, the majority of which from natural infection rather than vaccine.

8/9/2021
Question: Mother of a 13-year-old patient was told by their PCP that interval between two dozes of Pfizer/Moderna vaccines in this age group should be 3 months instead of 3-4 weeks and that this will reduce chances of cardiac complications due to this vaccine. Please share your opinion.

Answer: I checked the CDC and ACIP websites. At this time, there are no recommendations to increase the time interval between the doses in the at-risk population (adolescent/young adults) or anyone else. There is no data regarding whether extending the interval reduces risk. The UK has extended the interval to 12-16 weeks among adults, but the rationale has been to increase the number of persons who receive the first dose since the first dose has very good efficacy and their vaccine supply is limited. Furthermore, most of the myocarditis cases have occurred following the second injection, occur in a very small number of cases and reassuringly, have been mild.

5/11/2021
Question: Is there any guidance for patients on low dose long-term steroids for autoimmune disease on the persistent protection of the COVID-19 vaccine? Is there any way to commercially check for persistent antibodies?

Answer: No information could be found regarding durability of antibody response in this group of patients. COVID-19 serologic tests are commercially available and there are several tests that look at various components of the virus. However, we currently do not know enough about duration of antibody response and predicting immunity. As a result, it is difficult to make conclusions about these test results. The CDC has discouraged antibody testing to assess post-vaccination immune response. A negative result does not necessarily mean that the vaccine was not successful. For now, it appears that more information is needed before these tests are ready for use outside of the research arena.

12/14/2020
Question: If a patient has had COVID-19 infection and recovered, do they need to be vaccinated? Should we check IgG to COVID-19 virus first and if not in protective range, then give the vaccine? How long should a person wait who had COVID-19 infection before getting the COVID-19 vaccine?

Answer: Yes. The COVID-19 vaccine is recommended in a patient that has a history of COVID-19, as recurrent infections have been reported. Several studies involving small numbers of patients have indicated that immune responses after a single dose of mRNA vaccine produces levels comparable to those in infection-naïve patients after two doses. This study confirmed that finding in more than 1,000 people. There is no need to check antibody levels. People with COVID-19 who have symptoms should wait to be vaccinated until they have recovered from their illness and have met the criteria for discontinuing isolation; those without symptoms should also wait until they meet the criteria before getting vaccinated. This guidance also applies to people who get COVID-19 before getting their second dose of vaccine. If your patient was treated for COVID-19 with monoclonal antibodies or convalescent plasma, he/she should wait 90 days before getting a COVID-19 vaccine.

For more information, please refer here (https://www.cdc.gov/coronavirus/2019-ncov/vaccines/faq.html).

Question: Does the Janssen (Johnson & Johnson) vaccine contain PEG?

Answer: No. The Janssen COVID-19 vaccine includes the following ingredients: recombinant, replication-incompetent adenovirus type 26 expressing the SARS-CoV-2 spike protein, citric acid monohydrate, trisodium citrate dihydrate, ethanol, 2-hydroxypropyl-β-cyclodextrin (HBCD), polysorbate-80, sodium chloride. You can view the vaccine fact sheet here. (https://www.janssenlabels.com/emergency-use-authorization/Janssen+COVID-19+Vaccine-Recipient-fact-sheet.pdf)

Question: I reviewed the FAQ section on the AAAAI COVID-19 resources for clinicians, and I did find your advice on the use of daily oral steroids and interaction with the COVID-19 vaccine. I have a 68 yo male patient who has received 80mg of kenalog intra-articularly recently, and will be 11 days out of the intra-articular injection by the time he receives his first COVID-19 vaccine. For patients receiving long-acting steroid regimens, would you recommend a 4 week vs 2 week waiting period prior to the vaccine, if possible?

Answer: It depends on whether this was a depot steroid injection or an immediate acting injection. If immediate acting, I think that two weeks is reasonable. Immune suppression with corticosteroids usually requires several weeks of therapy, although depot injections can sustain the steroid dose for up to 6 weeks.  In that case, receiving the vaccine as soon as possible is preferred, before the immunosuppression begins.

Question: What recommendations can be given to patients who have been vaccinated regarding what they should do if exposed to a person with COVID-19?

Answer: Vaccinated persons with an exposure to someone with suspected or confirmed COVID-19 are not required to quarantine if they meet all of the following criteria: 

• are fully vaccinated (two weeks or more after the final vaccine dose), 
• are within 3 months following receipt of the final dose,
• and have remained asymptomatic since the current exposure. 

1/18/2021
Question: Should a patient who takes Singulair and Symbicort discontinue these medications two weeks prior and two weeks after the COVID19 vaccine? If these medications modify the immune system should these medications be held? 

Answer: No, there is no impact on an individual’s ability to respond to the vaccine and control of asthma is essential! There is no data to suggest that inhaled corticosteroids and/or leukotriene receptor antagonists impact on immunogenicity of the mRNA COVID-19 vaccines.

Question: CDC recommendations say not to pre-treat with antihistamines so as to not “mask” a reaction. However, I think for those patients that have known allergies or a background of allergies, pre-treatment makes sense. We tell patients to pre-treat before immunotherapy, to pre-treat before Aspirin desensitization, and pre-treat in some cases before OIT. Antihistamine pretreatment can blunt the severity of a reaction and buy time in management, which might be an advantage in venues where the vaccine is being given by personnel who are not trained in allergy management. Why not pre-treat before the vaccine in patients that have a background of allergy? 

Answer: Antihistamines are not contraindicated and can be given before the vaccination, although this approach is not recommended as a routine. One can make arguments either way as to whether this would hide or prevent a more serious reaction. In cases where the vaccine is administered without immediate availability of medical expertise, I would be concerned that the staff might miss a serious reaction if initial symptoms are blunted by the administration of the antihistamine before the vaccination.

Question: I assume with high dose steroids (>20mg/day) for prolonged periods, that the COVID vaccine should be deferred until at least several weeks. Any guidance with low dose or IM steroids and timing of COVID-19 vaccine?

Answer: Daily oral steroids may interfere with the antibody response to the vaccine based on data with other immunosuppressives and flu vaccine. If the dose can be safely stopped, then waiting two weeks may be a reasonable approach. If the steroids cannot be stopped, we would not delay administration of the vaccine as the risks associated with COVID infection outweigh the potential impaired response.

Question: Should a patient delay allergen immunotherapy (AIT) because they are receiving one of the mRNA COVID 19 vaccines?

Answer: The recommendations for 48 hours have not changed, but the rationale behind the 48 hours is to allow the clinician to recognize the cause should any reaction occur. There are no contraindications to giving an allergy shot and a vaccine on the same day.

12/29/2020
Question: Is there any cross-reactivity between gelatin and PEG? I have a patient who experienced anaphylaxis to gelatin in vaccine and foods. Is she likely to react to the COVID-19 vaccines? 

Answer: There is no gelatin in either the Pfizer or Moderna vaccine. To my knowledge there is no cross reactivity between PEG and gelatin. PEG is not found in other vaccines, except for Hepatitis A. If she had anaphylaxis to a vaccine other than the Pfizer or Moderna, then a 30-minute observation period is recommended. 

1/7/2021
Question: We are a large allergy and asthma group and many patients, due to the new vaccine, are asking if we test for polyethylene glycol and polysorbate. Is there a protocol in place for this? Your information on this matter will be greatly appreciated.

Answer: Our Task Force would not recommend routine skin testing for PEG in patients prior to vaccination unless they have a history of a severe allergic reaction to an injectable medication, or a history of a possible reaction to PEG. Skin testing is not standardized and the predictive value of skin testing is not known. Skin testing to PEG has been associated with systemic reactions. Furthermore, it is still not known if an allergy to PEG is the reason for allergic reactions to the SARS-CoV-2 vaccine. Routine testing, given these unknowns, may exclude people from receiving the vaccine unnecessarily, but could also potentially clear a patient for the vaccine who could still have a reaction. We refer you to 2 articles from JACI-IP in the last 2 years that may offer more insight: Polyethylene Glycol: Not Just a Harmless Excipient (jaci-inpractic e.org) and Polyethylene Glycol-Induced Systemic Allergic Reactions (Anaphylaxis) (jaci-inpractice.org)

Question: As a practicing allergist/ immunologist, I perform patch testing at my office for the evaluation of contact dermatitis/ urticaria. Over the years, I have noticed that several patients have positive patch tests to PEG, one of the components of the Pfizer and Moderna COVID-19 vaccines. Indeed, when eliminating products that contain PEG, the skin symptoms abate. What advice shall I give these patients in terms of whether to receive the now available vaccines, or not? Please note that some of these patients have severe contact allergies to PEG.

Answer: We would suggest that the patient be skin tested for an IgE-mediated reaction to PEG. Contact dermatitis secondary to PEG is not IgE-mediated, so we don’t know what the risk would be for vaccination. The patient should also be queried about systemic reactions to medications or products that contain PEG.

Question: How should we treat patients with mastocytosis and the COVID Vaccines?

Answer: We do not see a contraindication for COVID 19 vaccination for mastocytosis patients. These patients would likely be in to the 30 minute wait group as they may have had a history of anaphylaxis (to any cause) separate from an mRNA vaccine or excipient in the vaccine.

12/23/2020
Question: I am giving COVID-19 Pfizer vaccines at our hospital. We have had two anaphylaxis to date. Because this will be their only injection of that dosage based upon CDC guidelines, and with paucity of data on benefits of IV or oral steroid in anaphylaxis immediate care: Should we be looking at recommendation to avoid steroids in treating these patients with anaphylaxis? Most respond readily to 1-2 doses of epinephrine thus far. Steroids may blunt any precious antibody response?

Answer: In general, steroids are not needed or indicated for treatment of anaphylaxis. Treatment should be injectable epinephrine. Indeed, the recent practice parameters indicate no proven utility for use of steroids in acute anaphylaxis (J Allergy Clin Immunol. 2020;145(4):1082-123). Therefore, in response to this question, the answer would be to not administer steroids, but to treat the anaphylaxis with injectable epinephrine.

Question: What advice should we give patients who are allergic to several medications about the COVID-19 vaccine?

Answer: At the date of this response (December 19, 2020), only the Pfizer-BioNTech COVID-19 is available for administration in the U.S.   This is a dynamic process, so stay current on any changes in recommendations.  A summary of current recommendations are as follows:

Patients with allergies to oral medications (including oral equivalent of injectable medications), foods, insect, latex and environmental allergens have no restrictions and are recommended to receive the vaccine, followed by a 15-minute observation period.

Patients with non-serious reactions to vaccines or other injectables also have no restrictions, and are recommended to receive the vaccine, followed by a 15-minute observation period.

Patients with a history of severe allergic reactions (eg anaphylaxis) to vaccines (other than Pfizer-BioNTech COVID-19) or history of severe allergic reaction to any injectable medication, should be assessed for risk.  The CDC ACIP suggests considering potential deferral of vaccination, and to observe for 30 minutes, if vaccination is given.

Patients with a history of severe allergic reactions (eg anaphylaxis) to any component of the Pfizer-BioNTech or Moderna vaccines should not receive the vaccine.

In all cases, equipment and medications should be available to treat any potential anaphylactic event.

Question: I’m trying to research if there’s any guidance on patients receiving immunotherapy for their allergies and getting the COVID vaccine. Specific question I have would be: Should allergy shots be held for any amount of time before or after the COVID vaccine?

Answer: We do not anticipate any contraindication for patients on AIT. However, it would be best to not get the 2 shots within 48 hours of each other to avoid confusion should a reaction occur.

12/14/2020
Question: I have a patient that was diagnosed with COVID-19 one month ago. She has had long-standing, uncontrolled allergic rhinoconjunctivitis, and she would like to start allergen immunotherapy. Would there be any reason to suggest a certain waiting interval after her diagnosis before starting AIT?

Answer: Provided your patient had a mild, uncomplicated clinical course of COVID there is no reason to delay immunotherapy. On the other hand, if your patient had a more severe course or is immunocompromised, then viral shedding can continue for >28 days. Aydillo T, et al. (1) reported that some immunocompromised people may shed infectious novel coronavirus for at least two months after diagnosis, rather than the 10 days demonstrated in uncomplicated cases. The patients in the study had become immunocompromised after receiving stem cell transplantation, immunosuppressive therapy, or chemotherapy for various cancers. I feel that we can apply this rationale to other immunocompromised conditions.

1) Aydillo T, Gonzalez-Reiche AS, Aslam S, van de Guchte A, Khan Z, Obla A, Dutta J, van Bakel H, Aberg J, García-Sastre A, Shah G, Hohl T, Papanicolaou G, Perales MA, Sepkowitz K, Babady NE, Kamboj M. Shedding of Viable SARS-CoV-2 after Immunosuppressive Therapy for Cancer. N Engl J Med. 2020 Dec 1. doi: 10.1056/NEJMc2031670. Epub ahead of print. PMID: 33259154

2) https://www.nejm.org/doi/full/10.1056/NEJMc2031670

12/14/2020
Question: If a patient has had COVID19 infection and recovered, then do they even need the vaccine? Or should we check IgG to COVID19 virus first and if not in protective range then give the vaccine?

Answer: Yes. The COVID Vaccine is recommended in a patient that has a history of COVID. There is no need to check antibody. Recurrent infections have been reported. It is felt that the vaccine will provide superior protection.

12/9/2020
Question: Post COVID we have been using albuterol inhaler for doing pre- and post-spirometry. There is discrepancy as how many puffs (2 or 4) of albuterol inhaler we use prior to post bronchodilation spirometry?

We have been using 4 puffs (1 puff each 1 minute apart) waiting 10 minutes before doing post bronchodilation spirometry. Wondering if this any data to validate that dosing and timing?

Answer: You are correct, although 30 seconds in between would be adequate, rather than 1 minute.

Sim YS, Lee JH, et al. (1) provide a very thorough review of pre- and post-bronchodilator spirometry. The recommended procedure for albuterol is as follows. In the albuterol (short-acting β2-bronchodilator) bronchodilator test, the subject fully exhales slowly, and sprays an albuterol metered dose of 100 µg (1 puff) while biting a valved chamber. The subject then slowly and deeply inhales until reaching TLC over 3–5 seconds, holds the breath for 5–10 seconds, and exhales. This procedure is repeated four times (total 400 µg of albuterol), at intervals of 30 seconds. After inhalation of the last medication, the spirometry test is conducted again between 10–20 minute (1)

Also relevant to your question is this technique appropriate in a post-COVID patient. Grandbastien M, Piotin A, et al. (2) published an exceptional paper in J Allergy Clinical Immunology Practice. They studied 106 patients with SARS-CoV-2 between March 4 and April 6, 2020, who were hospitalized in the Chest Diseases Department of Strasbourg University Hospital; 23 had asthma.

The authors did not observe any increase in severe exacerbation with the development of SARS-CoV-2 pneumonia. This result is not in line with other respiratory viruses, such as Rhinovirus. In contrast to other respiratory viruses, SARS-CoV-2 may not be a risk factor for severe asthma exacerbation.

They further report that several hypotheses can be raised. ACE2 has been shown to be the functional receptor of SARS-CoV-1. This receptor is abundantly expressed in type I and type II pneumocytes, whereas bronchial epithelial cells exhibit only weak staining.

This study suggests that the risk factors for hospitalization in asthmatic patients were related more to the risk factors of SARS-CoV-2 pneumonia than to asthma.

In summary, in contrast to other viral respiratory infections, SARS-CoV-2 pneumonia did not appear to induce severe asthma exacerbation.

References:

1) Sim YS, Lee JH, Lee WY, et al. Spirometry and Bronchodilator Test. Tuberc Respir Dis (Seoul). 2017;80(2):105-112. doi:10.4046/trd.2017.80.2.105

2) Grandbastien M, Piotin A, Godet J, et al. SARS-CoV-2 Pneumonia in Hospitalized Asthmatic Patients Did Not Induce Severe Exacerbation. J Allergy Clin Immunol Pract. 2020;8(8):2600-2607. doi:10.1016/j.jaip.2020.06.032

Some answers have been updated to reflect changing circumstances and information since the individuals submitting the questions were originally provided with a response. While we’re working on keeping answers updated as best we can, information continues to evolve rapidly. Please email us at practicematters@aaaai.org with concerns or additional questions.