Skin testing, graded dose challenges guide hesitant patients to full COVID-19 vaccination
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Key takeaways:
- 80.6% of hesitant patients tolerated the COVID-19 vaccine.
- 84% of patients with a reaction to the COVID-19 vaccine completed vaccination.
- Previous drug and vaccine reactions do not contraindicate vaccination.
Patients with an adverse reaction to a COVID-19 vaccine can receive future doses, suggesting that their previous symptoms were not mediated by IgE, according to a letter published in Annals of Allergy, Asthma and Immunology.
Also, histories of reactions to other drugs and vaccines do not contraindicate the use of COVID-19 vaccines, Ari Heffes-Doon, MD, chief pediatric resident at New York University Long Island School of Medicine, and colleagues wrote.
In July 2021, two medical practices offered skin testing and graded-dose challenges to 62 patients (mean age, 47 years; 56 women; 53.2% white) who were hesitant about getting a COVID-19 vaccine.
Skin testing included percutaneous (1:1) and intradermal (1:100 and 1:10 dilution) administration. Graded dose challenges involved 10%, 30% and 60% doses administered every 30 minutes.
These patients had previous reactions to a COVID-19 vaccine (31.7%), previous reactions to other vaccines (29.3%) or a previous adverse drug reaction (33%). Medical providers performed 56 skin tests and 55 graded-dose challenges among these patients.
Also, 50 (80.6%) of the 62 patients received a full dose of a COVID-19 vaccine and were considered vaccine-complete, and the other 12 (19.4%) were deemed vaccine-incomplete.
There were 18 (29%) patients symptomatic during skin testing or graded dose challenges, including nine who were vaccine-complete and nine who were vaccine-incomplete.
Three of the patients who received skin testing had positive results, including one vaccine-complete patient with a previous reaction to a COVID-19 vaccine, and two who did not have a previous reaction to a COVID-19 vaccine or any graded dose challenge.
Also, 50 (90.9%) of the patients who had the 55 graded dose challenges were vaccine-complete and five were vaccine-incomplete.
The 25 (40.3%) patients with a prior reaction to a COVID-19 vaccine included 21 who had skin testing, with 14 for the Pfizer-BioNTech (BNT162b2) vaccine, one for the Moderna (mRNA-1273) vaccine and six for the Johnson & Johnson (Ad26) vaccine.
Only one of these patients had a positive skin test, and this patient was vaccine-complete. The 20 patients who had negative skin tests included 16 who were vaccine-complete and four who were vaccine-incomplete.
These four vaccine-incomplete patients included one who experienced chest tightness and pruritis during the skin test and then declined additional tests. The other three aborted testing due to symptoms as well.
The four patients who had a prior reaction to a COVID-19 vaccine but who did not receive skin testing were vaccine-complete. Three of these patients did not get skin testing because they were on antihistamines, and one did not due to personal preferences.
There were 24 graded-dose challenges for 25 patients with a prior reaction to a COVID-19 vaccine, including 21 patients who were vaccine-complete. Challenges included 16 for Pfizer, one for Moderna and seven for Johnson & Johnson.
Four of the vaccine-complete patients reported generalized, oral or facial pruritis or chest tightness. All three patients who were vaccine-incomplete had negative skin tests and aborted their graded-dose challenges due to chest tightness, dysphagia or face tingling.
Eleven of the 13 patients (84.6%) with a previous reaction to the Pfizer vaccine were vaccine-complete. Similarly, nine of the 11 patients (81.8%) with a previous reaction to the Moderna vaccine who had a graded dose challenge were vaccine complete.
The 37 patients who did not have a previous reaction to a COVID-19 vaccine included 26 with a history of drug allergies and 23 with reactions to other vaccines. Also, 33 of these 35 patients (94.3%) who had a skin test had negative results.
These patients with negative results included 27 (81.8%) who were vaccine-complete. Three of the six patients who were vaccine-incomplete did not have graded dose challenges because they experienced symptoms during the skin test, and one declined due to personal preference. Two aborted the graded dose challenges due to symptoms during these challenges.
Additionally, 29 of the 31 (93.5%) patients who did not have a previous reaction to the COVID-19 vaccine and who did have a graded dose challenge were vaccine-complete, with 23 taking the Pfizer vaccine and six taking the Johnson & Johnson vaccine.
Five of these patients reported subjective symptoms, including tremulousness, oral or ear pruritis, cheek numbness, palmar pruritis, and cough with postnasal drip, but there were no objective findings. Two of these patients were vaccine-incomplete and had negative skin tests, but they aborted graded dose challenges due to symptoms.
Based on these findings, the researchers concluded that vaccine excipient skin testing has low utility in predicting tolerance to vaccines. The researchers reported 80.6% vaccine tolerance among these patients and that 84% of the patients who reported adverse reactions to a previous dose of a COVID-19 vaccine were vaccine-complete regardless of the COVID-19 vaccine they took previously.
Also, about 78% of the patients with reactions to other vaccines, other drugs or both were vaccine-complete. There was no statistical difference, the researchers continued, in vaccine completion between the patients who had a previous reaction to a COVID-19 vaccine (87.5%) and those who did not have a previous reaction (93.5%) as well.
The researchers said that these findings confirm that patients who had previous reactions to a COVID-19 vaccine can receive new doses and that those previous reactions might not have been mediated by IgE.
By offering skin testing and graded dose challenges, the researchers said, these allergy offices decreased vaccine hesitancy and completed vaccination series in most patients who were hesitant to get a COVID-19 vaccine.
Perspective
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These are significant findings in that they provide further evidence that patients with a history of prior reaction to COVID-19 vaccines or multiple drug allergies are able to safely receive COVID-19 vaccines.
Also, these findings are similar to my clinical experience. Many patients report symptoms that are not IgE-mediated, and, indeed, they can proceed to vaccination.
I am struck that the patients in this study likely felt very heard and listened to, as their concerns regarding their reactions were documented carefully and then testing and graded challenges were performed. Listening to our patients and engaging in shared decision-making is some of the most important work we can do as physicians.
As the authors note, this paper relies on patient recall of their reactions. A study of a cohort of patients whose reactions are not affected by recall bias and with a focus on patients who experienced objective symptoms would be an interesting contribution to the literature.
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