CASE 1: Egg Allergy
Q: AG is a 29-year-old woman who is hesitant about getting the influenza vaccine and is getting it only because her employer requires it. While reading the screening and consent form, she mentions she has an egg allergy, and the influenza vaccine contains egg. She can tolerate foods containing eggs, such as bread and cake, but she has experienced hives and itching after eating scrambled eggs. What should the pharmacist advise?
A: Most flu vaccines are grown in eggs and include small amounts of egg protein called ovalbumin.1 Cell culture-based (Flucelvax Quadrivalent) and recombinant (Flublok Quadrivalent) influenza vaccines are completely egg free. Approximately 0.2% of adults and 1.3% of children have an egg allergy. It should be noted that in describing her reaction, AG said she experienced hives and itching after consuming lightly cooked eggs. Studies have been conducted to assess the safety of influenza vaccines in individuals who have egg allergies. All individuals with egg allergies in the study, even those with a history of anaphylaxis, received the trivalent inactivated influenza vaccine without serious reactions. Given that AG does not have a history of angioedema or other serious reactions to egg, the CDC recommends such patients receive any licensed form of the influenza vaccine at a pharmacy. Had AG reported a history of serious reactions to eggs, she should have been instructed to receive the influenza vaccine in an inpatient or outpatient medical center under provider supervision, not in a pharmacy. If AG has an allergic reaction to the influenza vaccine with angioedema and/or respiratory distress, the emergency medical system should be activated and a 0.3-mg dose of epinephrine administered intramuscularly, using a premeasured or prefilled syringe or an autoinjector, should be delivered in the midouter thigh while awaiting emergency medical response.2,3
CASE 2: Syncope
Q: JG is a 17-year-old girl who came to the pharmacy with her mother to get a HPV vaccine. JG is afraid of needles and vaccines and says she had heard about teenagers who have fainted after receiving the human papillomavirus (HPV) vaccine. She asks about syncope after vaccination and how it could be prevented and treated. What should the pharmacist tell her?
A: Syncope, or fainting, is caused A by decreased blood flow to the brain that leads to temporary loss of consciousness. Although syncope can occur with any vaccine, it is most common after HPV, meningococcal, and tetanus, diphtheria and pertussis vaccines. In addition, syncope is reported more frequently (62%) in adolescents aged 11 to 18 years. Although patients recover from syncope almost immediately, the potential injuries associated with fainting and falling are of greater concern. Per the CDC, 12% of serious syncope episodes reported to the Vaccine Adverse Event Reporting System resulted in head injuries.4,5
Typically, when patients present with a fear of needles or vaccination, the pharmacist should either reassure about the procedure or simply comfort them and consider providing them with a beverage or snack. Most importantly, preventing complications and head injuries from syncope require preparation prior to vaccination and quick action if syncope occurs. Make sure the patient is lying down or seated during vaccination. Monitor patients closely for 15 minutes after they are vaccinated. If syncope occurs, have the patient lie flat and maintain an open airway. Apply a cool, damp cloth to the face and neck and elevate the feet. Monitor the patient closely until full recovery and activate the emergency medical if the patient does not recover immediately or has been injured.4,5
CASE 3: Subdeltoid Bursitis
Q: ST is a 70-year-old woman who is getting her influenza and pneumococcal vaccines. She asks to speak with the pharmacist, as she had read about adverse effects of intramuscular vaccines, including shoulder bursitis or subdeltoid bursitis. What information should the pharmacist provide?
A: Subdeltoid bursitis following intramuscular (IM) vaccination, also called shoulder injury related to vaccine administration (SIRVA), presents as shoulder pain and limited range of motion following IM injection, owing to an anti-inflammatory reaction. Patients who suffer from SIRVA experience pain at rest that worsens with movement. A retrospective study of 3 million individuals who received the influenza vaccine showed 16 cases of subdeltoid bursitis within 2 days of vaccine administration. SIRVA may be treated with anti-inflammatory medications, ice, OTC or prescription analgesics, physical therapy, and rest.6
The correct anatomical location of an IM injection is in the lower two-thirds of the deltoid, and the appropriate length needle must be selected based on patient muscle mass to reduce the risk of injecting too deeply, past the muscle and into the bursa. Patients who experienced SIRVA were noted to have received the injection higher than recommended. The CDC has developed and disseminated guidelines for appropriate IM vaccine administration technique and needle selection.6,7
CASE 4: COVID-19 Vaccine
Q: JS is a 42-year-old woman who is getting her second dose of the Moderna COVID-19 vaccine. She was initially hesitant to get the vaccine, but her employer mandates it. JS said she felt fine after the first dose, aside from fatigue on the evening of the vaccination. She is nervous about the second dose because she has heard and read mixed reports about patient reactions. JS inquires about self-care following this dose. What information can the pharmacist provide?
A: Some individuals do have adverse effects (AEs) from the COVID-19 vaccines, and JS is right to prepare for self-care to prevent and manage AEs. On a positive note, the reported AEs are the symptoms of building immunity and protection. Reported local AEs at the injection site include pain, redness, and swelling. Systemic reactions include chills, fatigue, fever, headaches, or nausea. OTC acetaminophen and ibuprofen are recommended to treat the AEs, unless a physician indicates otherwise. It is not recommended that patients take either of these agents prior to the vaccination. Nonpharmacologic recommendations for local reactions include the application of a cold, wet washcloth over the injection site and lightly moving the arm that has received the injection after vaccination. Nonpharmacologic recommendations for systemic reactions include drinking plenty of water and wearing loose-fitting clothing to reduce discomfort from fever.8
About The Authors
Ammie Patel, PharmD, BCACP, is a clinical assistant professor of pharmacy practice and administration at Ernest Mario School of Pharmacy at Rutgers, The State University of New Jersey in Piscataway, and an ambulatory care specialist at RWJBarnabas Health Primary Care in Shrewsbury and Eatontown, New Jersey.
Rupal Patel Mansukhani, PharmD, FAPhA, CTTS, is a clinical associate professor at Ernest Mario School of Pharmacy at Rutgers, The State University of New Jersey in Piscataway, and a transitions-of-care clinical pharmacist at Morristown Medical Center in New Jersey.
1.Li JT, Rank MA, Squillace DL, Kita H. Ovalbumin content of influenza vaccines. J Allergy Clin Immunol.2010;125(6):1412-1412. doi:10.1016/j.jaci.2010.03.009
2.Flu vaccine and people with egg allergies. CDC. Updated December 10, 2021. Accessed June 2, 2022. https://www.cdc.gov/flu/prevent/egg-allergies.htm#algorithm
3.Greenhawt MJ, Spergel JM, Rank MA, et al. Safe administration of the seasonal trivalent influenza vaccine to children with severe egg allergy. Ann Allergy Asthma Immunol. 2012;109(6):426-430. doi:10.1016/j.anai.2012.09.011
4.Syncope after vaccination—United States, January 2005-July 2007. CDC. Morb Mortal Wkly Rep.2008;57(17):457-460. https://www.cdc.gov/mmwr/preview/mmwrhtml/mm5717a2.htm
5.Fainting (syncope) after vaccination. CDC. Updated August 25, 2020. Accessed June 2, 2022. https://www.cdc.gov/vaccinesafety/concerns/fainting.html
6.Hesse EM, Navarro RA, Daley MF, et al. Risk for subdeltoid bursitis after influenza vaccination: a population-based cohort study. Ann Intern Med. 2020;173(4):253-261. doi:10.7326/M19-3176
7.Vaccine administration. CDC. Updated April 22, 2022. Accessed June 2, 2022. https://www.cdc.gov/vaccines/hcp/acip-recs/general-recs/administration.html8.Vaccines for COVID-19. CDC. Updated May 17, 2022. Accessed June 2, 2022. https://www.cdc.gov/coronavirus/2019-ncov/vaccines/index.html