Review outlines common allergic reactions, testing protocols following vaccination
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Delayed hypersensitivity to vaccines is not uncommon but also does not typically contraindicate further vaccination, and patch testing can be used to determine the cause, according to a study published in Allergy & Asthma Proceedings.
Marcella R. Aquino, MD, an allergist and immunologist in the department of pediatrics at Hasbro Children’s Hospital in Providence, Rhode Island, and colleagues examined published reviews and case reports in PubMed and data from the CDC.
In one study, researchers reported delayed large local injection-site reactions to the Moderna SARS-CoV-2 vaccine in 0.8% of recipients after the first dose and 0.2% after the second dose, including erythema, induration and tenderness, typically resolving after 4 or 5 days.
Also, the review cited a series of 12 patients who developed delayed local large reactions to the Moderna vaccine, with onset between 4 and 11 days and symptom resolution between 2 and 11 days with antihistamine and corticosteroid treatment.
Another series of 16 patients with delayed cutaneous reactions to the Moderna mRNA SARS-CoV-2 vaccine demonstrated similar findings, with 15 patients developing erythematous painful local reactions near the injection site. Reactions occurred a median of 7 days after injection and lasted a median of 5 days with corticosteroid, antihistamine and cold compress treatment.
The Moderna and Pfizer-BioNTech SARS-CoV-2 vaccines include polyethylene glycols (PEG). Overall reactions to PEG are rare, the researchers wrote. But PEG products with higher molecular weights have been associated with anaphylaxis reactions, and products with lower molecular weights have been associated with delayed-type hypersensitivity reactions (DTHRs).
The available SARS-CoV-2 vaccines include polysorbates as well, the researchers continued. These fatty acid esters of polyoxythylene sorbitan can potentially cross-react. And although researchers did not find delayed cutaneous reactions to polysorbate 80, it is structurally related to PEG with implications in nonimmunologic anaphylactoid reactions.
Formaldehyde and thimerosal, used as preservatives in some vaccines, may cause allergic reactions. The researchers reported three vaccine reactions — one to hepatitis B vaccine and two to influenza vaccines — due to formaldehyde and one due to thimerosal, also from an influenza vaccine.
Additional excipients aluminum, gelatin and antibiotics — the most common being neomycin, gentamycin and polymyxin B — have also been implicated in delayed vaccine reactions.
Patients with histories of DTHR to vaccines may delay or skip other vaccinations, according to the researchers, who encouraged clinicians to conduct patch testing for those with histories of nodule formation or contact dermatitis.
Patients with local reactions do not need evaluation, the researchers continued, but patch testing should be considered for those with delayed cutaneous reactions. Patch testing improves quality of life overall, the researchers added, because many vaccine components are contact allergens that patients encounter in daily life as well.
Further, the researchers urged clinicians to engage in shared decision-making and discuss the potential for reactions after vaccination with patients who have histories of DTHRs as well as management strategies to ensure safe and satisfactory outcomes.
Perspective
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This publication and literature review is a nice summary of delayed reactions from Aquino and colleagues. It covers the most important components we consider when evaluating patients with delayed vaccine reactions. My experience is similar, and the important message is that the vast majority of delayed reactions are not a contraindication for further COVID-19 vaccination.
Also, the review emphasizes that shared decision-making is an important part of any medical visit. As physicians, we have the knowledge and data to support our process of giving information to patients. However, shared decision-making then stresses the importance of understanding the patient perspective and coming to a mutual decision that is best for that individual patient after the patient understands all aspects.
The concept of shared decision-making has been emerging in the field of medicine for the past few years. It is a model that really stresses the importance of communication from both the physician and patient side. There should be a focus on mutual respect and face-to-face direct communication, rather than emails, as well as on active listening.
We still need to better understand the cause of COVID-19 anaphylactic and immediate allergic reactions, however. There are some initial data and considerations for etiology, but more research is needed.
But the most important message remains the idea that the vast majority of delayed reactions are not a contraindication for further COVID-19 vaccination. Physicians can help guide care when patients have concerns about a prior vaccine reaction.
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