You may have seen that the CDC and its Advisory Committee on Immunization Practices (ACIP) has updated/changed their guidelines on patient’s with egg allergy.  Here is a brief overview of the new recommendations or click the link to read them on the CDC’s website:

1. They no longer recommend a 30 min observation period after receiving the vaccine for egg allergic patients.
2. The vaccine can be administered in an inpatient or outpatient medical setting (which does not exclude retail pharmacy locations).

3. Any vaccine may be used so long as it is appropriate for age and health status.

4.  Patients who have a reaction more severe than hives such as respiratory distress, recurrent vomiting, etc. OR  who required epinephrine or “other emergency medicine intervention” may be given the vaccine in an outpatient setting by a medical professional trained to recognize and manage severe allergic reaction.

5.  Severe reaction to a previous vaccine is a contraindication for receiving future vaccines.

I have several thoughts on this new recommendation the first being:  A patient with a known egg allergy (even those that can eat eggs cooked in cakes/cookies SHOULD NOT be receiving a flu vaccine in a retail pharmacy setting.   NOPE.

What does “a health care provider who is able to recognize and manage severe allergic conditions” really mean anyway?  This extremely vague description allows for a multitude of interpretations.  All medical professionals including CNAs, in my opinion, should be able to recognize a severe allergic reaction.  I even  think first responders educated by the American Red Cross should have specific training regarding anaphylaxis in all First Aid/CPR and Basic Life Support courses.   The real question comes down to being able to “manage” the reaction.

What does managing the reaction entail according to the Advisory Panel?  We don’t know for sure since they didn’t spell it out for us  but since retail pharmacies are not excluded they must feel that a retail pharmacist can manage a severe allergic reaction.  I am here to say we can’t.  Can we administer epinephrine? YES.  Can we call 911?  YES.  Can we begin basic life support if needed?  YES.  But is that “managing” a reaction.  NO; its reactive no proactive. We are not directing; we are responding.

While I am talking about the Advisory Panel, maybe we should also discuss who is on the Advisory  Committee on Immunization Practices (ACIP).  Members include professors of  infectious disease, epidemiology, pediatrics,  obstetrics and gynecology and health department directors. In addition to the members there are also people on the committee that are part of the panel based on the position they hold.  These “ex officio” members include a policy advisor for CMS (Center for Medicare Services), a physician with the DoD (Department of Defense), preventive medicine consultant physician with the DVA (Department of Veteran’s Affairs), director of vaccines with the FDA, clinical research director with NIH (National Institutes of Health).

The ACIP also has input via a liaison representative from the American Academy of Family Physicians, American Academy of Pediatrics, American Academy of Physician Assistants, American College of Nurse Midwives, American College of Obstetrics and Gynecology, American College of Physicians, American Geriatric Society, American Medical Association, American Nursing Association, American Osteopathic Association,  Association of Immunization Managers, Biotechnology Industry Organization, Infectious Disease Society of America, Canadian National Advisory Committee on Immunization, National Association of Pediatric Nurse Practitioners, National Vaccine Advisory Committee, Pediatric Infectious Disease Society, Pharmaceutical Research and Manufacturers of America, Society for Healthcare Epidemiology of America, Mexico’s National Immunization Counsel and Child Health Programs, National Association of County and City Health Officials, Council of State and Territorial Epidemiologists and interestingly the American Pharmacist Association (APhA).

Congrats if you made it all the way through that cumbersome list!  I know that was a rough read but I did it to draw attention to a massive oversight…

Guess what I don’t see on that panel? AN ALLERGIST!! I’ve read through the members several times and I’ve only seen the word “immunology” mentioned once (and that was because the National Association of Pediatric Nurse Practitioners liaison is the Director of Infectious Disease/Immunology/Infection Control. Even if i missed ONE immunologist on the ACIP, why aren’t there more?  Perhaps the Clinical Immunology Society and the American Association of Immunologists should be included on the panel.  Heck, why not add the Canadian Society for Immunology since the Canadian National Advisory Committee on Immunization and the Mexican National Immunization Counsel and Child Health Programs are represented.

Surely I am not the only person to have a big problem with this?  What do immunologist actually think about this new recommendation?  My gut feeling is they don’t like it especially considering the variable and often unpredictable nature of immune response.

What I can tell you is that my personal pediatrician/nurse practitioner refused to give the vaccine to E  even though his allergist had okayed the shot to be given in her (allergist) or the pediatrician’s office.  Furthermore, there is no14519727_10153751280376364_8020140383644708749_n way I will be administering a flu vaccine to an egg allergic patient in my pharmacy, regardless of the patient’s ability to eat cooked eggs and here is why…

With permission from her mother, I wanted to share this picture. This is the arm of child who can eat eggs baked into foods (but avoids scrambled eggs) after receiving the flu vaccine. The picture was taken an hour after diphenhydramine (Benadryl), Cortisone, and ice.

What are your thoughts on this?  Do you think immunologists should be included in the CDC’s ACIP?  Would you give or get the vaccine in a retail pharmacy setting knowing that a reaction like this or worse is possible?