Ann Allergy Asthma Immunol 120 (2018) 49–52

Contents lists available at ScienceDirect

Practice Parameters

Administration of inﬂuenza vaccines to egg allergic recipients:
A practice parameter update 2017☆
Matthew Greenhawt, MD, MBA, MSc; Paul J. Turner, BM, BcH, FRACP, PhD; John M. Kelso, MD

A R T I C L E

I N F O

Article history:
Received for publication October 9, 2017.
Accepted for publication October 12, 2017.

Reprints: Matthew Greenhawt, MD, MBA, MSc, Section of Allergy and Clinical Immunology, Children’s Hospital Colorado, University of Colorado School of Medicine, 13123
East 16th Avenue, Box 518, Anschutz Medical Campus, Aurora, CO 80045; E-mail: Matthew.Greenhawt@childrenscolorado.org.
Disclosures: The following is a summary of interests disclosed on Work Group members’ conﬂict of interest disclosure statements (not including information concerning family
member interests). Completed conﬂict of interest disclosure statements are available on request and are available at https://www.allergyparameters.org/. Conﬂicts of interest
disclosure statements for Joint Task Force on Practice Parameters (JTFPP) are also available there. Dr Greenhawt is supported by grant K08HS024599 from the Agency for Healthcare Quality and Research; is an expert panel and coordinating committee member of the National Institute of Allergy and Infectious Diseases–sponsored Guidelines for PeanutAllergy Prevention; has served as a consultant for the Canadian Transportation Agency and Aimmune Therapeutics; is a member of physician/medical advisory boards for Aimmune,
Nutricia, Kaleo Pharmaceutical, Intrommune, Nestle, and Monsanto; is a member of the scientiﬁc advisory council for the National Peanut Board; has received honorarium for
lectures from Thermo Fisher, the Western/Pennsylvania/Aspen/New York/Swineford allergy societies, the ACAAI, and the EAACI; and is a member of the JTFPP. Dr Turner is inreceipt of a Clinician Scientist Award funded by the UK Medical Research Council (MR/K010468/1). He has received funding from the UK Departments of Health policy research
program (National Vaccine Evaluation Consortium); the European Union’s Seventh Framework Program for research, technological development, and demonstration (grant
agreement 312147, iFAAM project); End Allergies Together, a 501(c)(3) nonproﬁt organization; and the National Institute for Health Research (NIHR) Biomedical Research Centre
based at Imperial College Healthcare National Health Service (NHS) Trust and Imperial College London. No other disclosures were reported. The JTFPP recognizes that experts
in a ﬁeld are likely to have interests that could come into conﬂict with development of a completely unbiased and objective practice parameter. To take advantage of thatexpertise, a process has been developed to prevent potential conﬂicts from inﬂuencing the ﬁnal document in a negative way. At the workgroup level, members who have apotential conﬂict of interest either do not participate in discussions concerning topics related to the potential conﬂict or, if they do write a section on that topic, the workgroupcompletely rewrites it without their involvement to remove potential bias. In addition, the entire document is reviewed by the JTFPP and any apparent bias is removed at thatlevel. Finally, the practice parameter is sent for review by invited reviewers and anyone with an interest in the topic by posting the document on the websites of the ACAAI and
the AAAAI. The JTFPP is a 12-member taskforce consisting of 6 representatives assigned by the AAAAI and 6 by the ACAAI. This taskforce oversees the development of practiceparameters, selects the workgroup chair(s), and reviews drafts of the parameters for accuracy, practicality, clarity, and broad utility of the recommendations for clinical practice.
Disclaimer: The American Academy of Allergy, Asthma, and Immunology (AAAAI) and the American College of Allergy, Asthma, and Immunology (ACAAI) have jointly accepted responsibility for establishing Inﬂuenza Vaccine: A Practice Parameter Update 2017. This is a complete and comprehensive document at the current time. The medical
environment is a changing environment, and not all recommendations will be appropriate for all patients. Because this document incorporated the efforts of many participants, no single individual, including those who served on the Joint Task Force on Practice Parameters, is authorized to provide an oﬃcial AAAAI or ACAAI interpretationof these practice parameters. Any request for information about or an interpretation of these practice parameters by the AAAAI or ACAAI should be directed to the executive oﬃces of the AAAAI and/or the ACAAI. These parameters are not designed for use by pharmaceutical companies in drug promotion. The views expressed here arethose of the author(s) and not necessarily those of the NHS, NIHR, or the Department of Health.
Published parameters are available at https://www.allergyparameters.org/.
Contributors: The Joint Task Force on Practice Parameters has made a concerted effort to acknowledge all contributors to this parameter. If any contributors have been excluded
inadvertently, the Task Force will ensure that appropriate recognition of such contributions is made subsequently. Workgroup Chair: Matthew Greenhawt, MD, MBA, MSc,
Department of Pediatrics, Children’s Hospital of Colorado, Section of Allergy and Immunology, University of Colorado School of Medicine, Aurora, Colorado. Joint Task Force on
Practice Parameter Members: David I. Bernstein, MD, Department of Clinical Medicine and Environmental Health, Division of Immunology, Allergy, and Rheumatology, University of Cincinnati College of Medicine, Cincinnati, Ohio; Joann Blessing-Moore, MD, Department of Immunology, Stanford University Medical Center, Palo Alto, California;
Chitra Dinakar, MD, Stanford University School of Medicine, Allergy & Asthma Clinical Chief, Stanford Health Care, Division of Pulmonary and Critical Care Medicine, Departmentof Medicine, Stanford University, Stanford, California; Matthew Greenhawt, MD, MBA, MSc, Department of Pediatrics, Children’s Hospital of Colorado, Section of Allergy and
Immunology, University of Colorado School of Medicine, Aurora, Colorado; Caroline Horner, MD, Department of Pediatrics, Division of Allergy, Immunology and Pulmonary
Medicine, Washington University School of Medicine, St Louis, Missouri; David A. Khan, MD, Department of Internal Medicine, Division of Allergy and Immunology, Universityof Texas Southwestern Medical Center, Dallas, Texas; David M. Lang, MD, Department of Medicine, Department of Allergy and Clinical Immunology, and the Allergy and Immunology Fellowship Training Program, Cleveland Clinic Foundation, Cleveland, Ohio; John Oppenheimer, MD, Department of Internal Medicine, New Jersey Medical School,
Morristown, New Jersey; Jay M. Portnoy, MD, Section of Allergy, Asthma & Immunology, The Children’s Mercy Hospital, University of Missouri-Kansas City School of Medicine,Kansas City, Missouri; Christopher C. Randolph, Center for Allergy, Asthma and Immunology, Yale Hospitals, Waterbury, Connecticut; Matthew Rank, MD, Division of Allergy,
Asthma, and Clinical Immunology, Mayo Clinic School of Medicine, Scottsdale, Arizona; Dana Wallace, MD, Department of Medicine, Nova Southeastern University, Davie, Florida.
Parameter Workgroup Members: Matthew Greenhawt, MD, MBA, MSc, Department of Pediatrics, Children’s Hospital of Colorado, Section of Allergy and Immunology, Universityof Colorado School of Medicine, Aurora, Colorado; John M. Kelso, MD, Division of Allergy, Asthma and Immunology, Scripps Clinic, San Diego, California; Paul J. Turner, BM, BCh,FRACP, PhD, Imperial College London and Imperial College Healthcare NHS Trust & Royal Brompton & Hareﬁeld NHS Foundation Trust, London, United Kingdom, and Departmentof Paediatrics, University of Sydney, Sydney, Australia. Invited Society Reviewers: Raghava Charya, MD, Bethesda, Maryland; Kathryn Convers, MD, Valrico, Florida; Sunita Kanumury,
MD, Denville, New Jersey; Sangeetha Kodoth, MD, Knoxville, Tennessee; James T. Li, MD, Rochester, Minnesota; and Jim Parkerson, MD, Fort Wayne, Indiana.
https://doi.org/10.1016/j.anai.2017.10.020
1081-1206/© 2017 American College of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.

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M. Greenhawt et al. / Ann Allergy Asthma Immunol 120 (2018) 49–52

Chief Editors: Matthew Greenhawt, MD, MBA, MSc; Paul J. Turner, FRACP, PhD; John M. Kelso, MD.
Members of the Joint Task Force on Practice Parameters: David Bernstein, MD; Joann Blessing-Moore, MD; Chitra Dinakar, MD; Matthew Greenhawt, MD; Caroline Horner,
MD; David Khan, MD; David Lang, MD; John Oppenheimer, MD; Jay Portnoy, MD; Christopher Randolph, MD; Matt Rank, MD; and Dana Wallace, MD.
☆This parameter was developed by the Joint Task Force on Practice Parameters, representing the American Academy of Allergy, Asthma, and Immunology and the American College of Allergy, Asthma, and Immunology.

Classiﬁcation of Recommendations and Evidence
Recommendation Rating Scale
Statement

Deﬁnition

Implication

Strong recommendation(StrRec)

A strong recommendation means the beneﬁts of the recommended approachclearly exceed the harms (or that the harms clearly exceed the beneﬁts inthe case of a strong negative recommendation) and that the quality of the
supporting evidence is excellent (grade A or B).* In some clearly identiﬁed
circumstances, strong recommendations may be made based on lesser
evidence when high-quality evidence is impossible to obtain and theanticipated beneﬁts strongly outweigh the harms.
A recommendation means the beneﬁts exceed the harms (or that the harms
clearly exceed the beneﬁts in the case of a negative recommendation), but
the quality of evidence is not as strong (grade B or C).* In some clearly
identiﬁed circumstances, recommendations may be made based on lesser
evidence when high-quality evidence is impossible to obtain and theanticipated beneﬁts outweigh the harms.
An option means that either the quality of evidence that exists is suspect(grade D)* or that well-done studies (grade A, B, or C)* show little clear
advantage to one approach vs another.

Clinicians should follow a strong recommendation unless aclear and compelling rationale for an alternative
approach is present.

Recommendation(Rec)

Option(Opt)

No recommendation(NoRec)No recommendation means there is both a lack of pertinent evidence (gradeD)* and an unclear balance between beneﬁts and harms.

Category of Evidence
Ia Evidence from meta-analysis of randomized controlled trials
Ib Evidence from at least one randomized controlled trial
IIa Evidence from at least one controlled study without
randomization
IIb Evidence from at least one other type of quasiexperimental
study
III Evidence from nonexperimental descriptive studies, such ascomparative studies
IV Evidence from expert committee reports or opinions or clinical experience of respected authorities or both

Clinicians should also generally follow a recommendation
but should remain alert to new information and sensitive
to patient preferences.

Clinicians should be ﬂexible in their decision making
regarding appropriate practice, although they may set
bounds on alternatives; patient preference should have asubstantial inﬂuencing role.
Clinicians should feel little constraint in their decision
making and be alert to new published evidence thatclariﬁes the balance of beneﬁt vs harm; patient
preference should have a substantial inﬂuencing role.

Workgroup members invited to participate in the parameter development are considered experts in the ﬁeld. Workgroup members
have been vetted for ﬁnancial conﬂicts of interest by the JTFPP,
and their conﬂicts of interest have been listed in this document andare posted on the JTFPP website at https://www.allergyparameters.org/. Where a potential conﬂict of interest is present, thepotentially conﬂicted workgroup member was excluded fromdiscussing relevant issues. The charge to the workgroup was
to use a systematic literature review, in conjunction with consensus expert opinion and workgroup-identiﬁed supplementary
documents, to develop a practice parameter that provides a comprehensive approach for the administration of inﬂuenza vaccines
to egg allergic recipients based on the current state of thescience.

Strength of Recommendation*
A Directly based on category I evidence
B Directly based on category II evidence or extrapolated recommendation from category I evidence
C Directly based on category III evidence or extrapolated recommendation from category I or II evidence
D Directly based on category IV evidence or extrapolated recommendation from category I, II, or III evidence
LB Laboratory based
NR Not rated

How This Practice Parameter Update Was Developed
The Inﬂuenza Vaccine and Egg Allergy Practice Parameter Workgroup was commissioned by the Joint Task Force on PracticeParameters (JTFPP) to develop practice parameters that address theadministration of inﬂuenza vaccines to egg allergic recipients.

PrefaceAnnual seasonal inﬂuenza vaccination remains the most effective means of protection against contracting inﬂuenza illness andpreventing spread of the disease among the population.1 Inﬂuenza infection is a signiﬁcant source of morbidity and mortality in the
United States. During the 2015–2016 inﬂuenza season, an estimated 308,232 persons were hospitalized in the United States
because of inﬂuenza, including 15,389 hospitalizations of children younger than 5 years.2 It is estimated that 23,607 deaths occur
each year in the United States as a result of inﬂuenza, including approximately 124 children.3 Egg allergy affects as many as 2% of US
children,4 and of these, 29% also have asthma.5 Therefore, egg allergic children are a subgroup who may be at higher risk forinﬂuenza-related complications. However, because most inﬂuenza vaccines are grown in embryonated chicken eggs and may containresidual egg protein (ovalbumin),1 they were contraindicated in thosewith egg allergy until recently.6

M. Greenhawt et al. / Ann Allergy Asthma Immunol 120 (2018) 49–52

New Developments
A large number of studies have reported inactivated inﬂuenza
vaccine (IIV) to be safe for egg allergic recipients, including thosewith a history of anaphylaxis to egg, with low rates of minor reactions among egg allergic recipients that are no greater than thoseincurred by non–egg allergic recipients.7 Furthermore, these studies
have demonstrated that special precautions, such as prevaccine skintesting or stepwise challenge, are unnecessary for risk stratiﬁcation.7
Moreover, the ovalbumin content in all IIV available in the UnitedStates is less than 1 μg per dose,1 an amount considered highly unlikely to cause reactions even in the most severely egg allergic
recipients. Two non–egg-based inﬂuenza vaccines have been introduced. One (ccIIV4) is grown in cell culture and in theory could
contain 50 fg of ovalbumin (1 fg equals 1e-9μg).1 It is approved forrecipients 4 years and older. The other (RIV, available both as trivalent RIV3 and quadrivalent RIV4) uses recombinant hemagglutinin
protein produced in an insect cell line and does not contain egg
protein.1 It is approved for patients 18 years and older.
Beginning in 2011, the Centers for Disease Control and Prevention (CDC) Advisory Committee on Immunization Practices (ACIP)
and the American Academy of Pediatrics (AAP) Committee on Infectious Diseases (COID) recommended that egg allergic patients
receive annual IIV, with certain precautions. Those with a historyof only hives after egg ingestion were recommended to receive thevaccine in a primary care setting and be observed for 30 minutes
after vaccination, whereas those with a history of more severereactions to egg were recommended to see an allergist for
vaccination.8,9An practice parameter on adverse reactions to vaccines was published in 2012, 10 with an update on inﬂuenza vaccination of
eggallergic patients published in 2013,11 which stated the following:• All patients with egg allergy of any severity, including anaphylaxis, should receive IIV annually, using any age-approved brandof IIV in an age-appropriate dose. Such patients can receive thevaccine as a single dose without prior vaccine skin testing.
• For egg allergic patients 18 years and older, either egg-based or
egg-free IIV can be used.
• Special precautions regarding medical setting and waiting periods
after administration of IIV to egg allergic recipients beyond thoserecommended for any vaccine are not warranted.
• For IIV, language that describes egg allergic recipients as being
at increased risk compared with non–egg allergic recipients or
requiring special precautions should be removed from guidelines and product labeling.
• All practitioners were reminded to be aware that although anaphylactic reactions are rare after vaccination, their immediate
onset and life-threatening nature require that all personnel andfacilities providing vaccinations of any kind have procedures inplace for anaphylaxis management.
In all the aforementioned guidelines, live attenuated inﬂuenza
vaccine (LAIV) was not recommended for use in egg allergic recipients. This is because LAIV also contains a very low level ofovalbumin (<0.24 μg per 0.2-mL dose),12 and at the time, no studies
demonstrating its safety in egg allergic recipients had been
published. Another concern raised regarded the possibility ofincreased risk for wheezing in patients with asthma after vaccine
administration,12 although the evidence base for this is limited.13
Since publication of the 2013 practice parameter update,12 additional data have been published regarding the safety of both IIV
and LAIV in egg allergic recipients. Two large multicenter, prospective cohort studies demonstrated the safety of LAIV in egg allergic
individuals.13,14 The CDC/ACIP and AAP/COID have updated their
guidelines for the 2017–2018 inﬂuenza season, 1,15 largely

51

adopting the recommendations made in the 2013 practiceparameter.11
The AAP/COID guidelines now state the following15:• “All children with an egg allergy of any severity can receive aninﬂuenza vaccine without any additional precautions beyond
those recommended for any vaccine.”• “IIV administered in a single, age-appropriate dose is well tolerated by recipients with a history of egg allergy of any
severity.”• “Special precautions for egg-allergic recipients of IIV are not warranted, because the rate of anaphylaxis after IIV administration
is no greater in egg-allergic than in non–egg-allergic recipients or from other universally recommended vaccines.”• “Standard vaccination practice for all vaccines in children should
include the ability to respond to rare acute hypersensitivity
reactions”
The CDC/ACIP, in its guidance for the 2017–2018 inﬂuenza
season,1 also states that persons with egg allergy of any severity
can receive any age-appropriate inﬂuenza vaccine but recommends that those who report having had reactions to egg that involve
symptoms other than hives receive the vaccine in a medical setting
supervised by a health care professional.
In addition, current guidelines from the Canadian National Advisory Committee on Immunization state, “Egg allergic individuals
may be vaccinated against inﬂuenza using inactivated TIV or QIV,or LAIV without prior inﬂuenza vaccine skin test and with the fulldose, irrespective of a past severe reaction to egg, and without any
extraordinary precautions.”16

Summary Statements
The purpose of this practice parameter update is to review newdata pertaining to the safety of inﬂuenza vaccines in egg allergic
individuals and provide recommendations regarding annual inﬂuenza vaccination in egg allergic individuals. This focused practiceparameter answers the following focused questions: (1) Is IIV safein egg allergic individuals, including those with a history of severereactions to egg ingestion? (2) Are special precautions necessary
to administer IIV to any egg allergic recipients? (3) Are non–eggbased IIV medically necessary in egg allergic patients in the agegroups for which they are approved? and (4) Is LAIV safe to administer to egg allergic individuals, including those with a historyof anaphylaxis to egg ingestion?
Summary Statement 1: Inﬂuenza vaccines should be administered to individuals with egg allergy of any severity, just as theywould be to individuals without egg allergy. Strength of recommendation: strong. Evidence level: A/B.
Data from 28 studies, covering 4,315 egg allergic patients, including 656 patients with severe egg allergy, describe uneventfuladministration of egg-based IIV without any reported cases ofanaphylaxis.7,17,18 Low rates of minor reactions such as hives havebeen noted to occur but at no greater rate than those occurring in
non–egg allergic controls.7 Ongoing analysis of the Vaccine Adverse
Event Reporting System data after the 2011 CDC guidelines recommended the administration of inﬂuenza vaccine to egg allergic
recipients has not demonstrated any increased reporting of allergic reactions, including anaphylaxis, in egg allergic individuals afterinﬂuenza vaccination compared with the general population.19 Similarly, the Canadian guidelines recommending no special precautions
for inﬂuenza vaccination of egg allergic recipients have been in placesince 2014, and no increase in adverse reactions have been
observed.20 Thus, all patients with egg allergy, irrespective of theseverity, including those with a history of anaphylaxis after egg

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ingestion, should receive inﬂuenza vaccine annually, using any ageapproved brand of inﬂuenza vaccine in an age-appropriate dose.
With respect to the current inﬂuenza vaccines in use in the UnitedStates, vaccine providers (eg, physician oﬃces, health care system
occupational/employee health sections, retail pharmacy chains providing vaccine services) do not need to inquire about egg allergy
status of recipients before the administration of any inﬂuenza
vaccine. Vaccine providers and screening questionnaires do notneed to ask about the egg allergy status of recipients of inﬂuenza
vaccine.
Summary Statement 2: No special precautions beyond those recommended for the administration of any vaccine to any patient arenecessary for administration of inﬂuenza vaccine to egg allergic individuals. Strength of recommendation: strong. Evidence level:
A/B.
Egg allergic patients can be vaccinated safely with inﬂuenza vaccines in the same manner as those without egg allergy. 11,15,16
Previously recommended precautions, such as choice of a speciﬁc
vaccine based on ovalbumin content (at least in countries where
the known ovalbumin content in all available IIV is <1 μg per dose),skin testing with the vaccine, and divided or graded dosing, areunnecessary.11,21 Similarly, speciﬁc waiting periods or special medical
settings for the administration of inﬂuenza vaccine to egg allergic
recipients are unnecessary.11,15,16
Anaphylaxis can occur rarely after the administration of any
vaccine to any patient at a rate of approximately 1 per million.7
Therefore, as per ACIP general recommendations on immunization, providers should be aware that “although anaphylactic reactions
are rare after vaccination, their immediate onset and life-threatening
nature require that all personnel and facilities providing vaccinations have procedures in place for anaphylaxis management.”22
Furthermore, as with any vaccine, patients who have had an anaphylactic reaction to inﬂuenza vaccination itself, as opposed to areaction to egg ingestion, should be evaluated by an allergist before
subsequent vaccinations.10
Summary Statement 3: Use of non–egg-based inﬂuenza vaccines (ccIIV3, RIV3, or RIV4) in egg allergic individuals in the agegroups for which they are approved is acceptable but not medically necessary or preferred. Strength of recommendation: moderate.
Evidence level: C/D.
Non–egg-based inﬂuenza vaccines (ccIIV3, RIV3, or RIV4), which
do not contain measurable quantities of egg protein, may be administered to egg allergic recipients. However, there is no medical
reason to do so, and there is no preference for the use of these vaccines in egg allergic recipients over egg-based vaccines.1 As withany vaccine, there are rare reports of anaphylactic reactions evento non–egg-based vaccines.23
Summary Statement 4: Live attenuated inﬂuenza vaccine (LAIV)
may be administered to patients with egg allergy of any severityin the age group for which it is approved (ages 2–49 years), in particular, countries and seasons when LAIV is recommended as anagent (based on effectiveness in prior seasons). Strength of recommendation: strong. Evidence level: A/B.
Three recently published studies have demonstrated that LAIV
is safe for use in egg allergic individuals of all ages, including thosewith anaphylaxis to egg ingestion.13,14,24 These reports collectively
describe 955 children with egg allergy, including 412 with a historyof anaphylaxis with egg ingestion, who have been safely vaccinated with LAIV without developing any immediate systemic
reactions. As with IIV, this is likely because of the low amount ofegg protein in the vaccine (<0.24 μg of ovalbumin per dose).12 CDC/
ACIP and AAP/COID acknowledge the safety of LAIV in egg allergic
recipients but recommend that it not be used in any population
during the 2017–2018 season because of concerns regarding
effectiveness.1,15

Conclusion
There is strong evidence that egg allergic individuals can safely
receive IIV or LAIV if the latter vaccine is recommended for use oncethe concerns regarding eﬃcacy have been resolved. Presence of egg
allergy in an individual is not a contraindication to receive IIV or
LAIV. Inﬂuenza vaccine recipients with egg allergy are at no greaterrisk for a systemic allergic reaction than those without egg allergy.
Precautions, such as choice of a particular vaccine, special observation periods, or restriction of administration to particular medical
settings, are not warranted and constitute an unnecessary barrier
to immunization. Vaccine providers and screening questionnaires
do not need to ask about the egg allergy status of recipients of inﬂuenza vaccine.
References[1] Grohskopf LA, Sokolow LZ, Broder KR, et al. Prevention and control of seasonal inﬂuenza with vaccines: recommendations of the Advisory Committee on
Immunization Practices—United States, 2017-18 Inﬂuenza Season. MMWR
Recomm Rep. 2017;66:1–20.
[2] Centers for Disease Control and Prevention. Estimated Inﬂuenza Illnesses,
Medical Visits, Hospitalizations, and Deaths Averted by Vaccination in the UnitedStates. https://www.cdc.gov/ﬂu/about/disease/2015-16.htm. Accessed January
15, 2017.
[3] Centers for Disease Control and Prevention (CDC). Estimates of deaths associated with seasonal inﬂuenza — United States, 1976–2007. MMWR Morb Mortal
Wkly Rep. 2010;59:1057–1062.
[4] Sicherer SH. Epidemiology of food allergy. J Allergy Clin Immunol. 2011;127:594–602.
[5] Branum AM, Lukacs SL. Food allergy among U.S. children: trends in prevalence and hospitalizations. NCHS Data Brief. 2008;1–8.
[6] Fiore AE, Uyeki TM, Broder K, Finelli L, Euler GL, Singleton JA. Prevention andcontrol of inﬂuenza with vaccines: recommendations of the Advisory Committee
on Immunization Practices (ACIP), 2010. MMWR Recomm Rep. 2010;6:1–62.
[7] Kelso JM. Administering inﬂuenza vaccine to egg-allergic persons. Expert Rev
Vaccines. 2014;13:1049–1057.
[8] Centers for Disease Control and Prevention (CDC). Prevention and control ofinﬂuenza with vaccines: recommendations of the advisory Committee on Immunization Practices (ACIP), 2011. MMWR Morb Mortal Wkly Rep. 2011;60:
1128–1132.
[9] American Academy of Pediatrics Committee on Infectious Diseases. Recommendations for prevention and control of inﬂuenza in children, 2011–2012.
Pediatrics. 2011;128:813–825.
[10] Kelso J, Greenhawt M, Li J, et al. Adverse reactions to vaccines practice parameter 2012 update. J Allergy Clin Immunol. 2012;130:25–43.
[11] Kelso JM, Greenhawt MJ, Li JT. Update on inﬂuenza vaccination of egg allergic
patients. Ann Allergy Asthma Immunol. 2013;111:301–302.
[12] MedImmune; FLUMIST® QUADRIVALENT [package insert]. Gaithersburg, MD,
2016.
[13] Turner PJ, Southern J, Andrews NJ, Miller E, Erlewyn-Lajeunesse M. Safety oflive attenuated inﬂuenza vaccine in young people with egg allergy: multicentre
prospective cohort study. BMJ. 2015;351:h6291.
[14] Turner PJ, Southern J, Andrews NJ, Miller E, Erlewyn-Lajeunesse M. Safety oflive attenuated inﬂuenza vaccine in atopic children with egg allergy. J Allergy
Clin Immunol. 2015;136:376–381.
[15] AAP Committee on Infectious Diseases. Recommendations for prevention andcontrol of inﬂuenza in children, 2017–2018. Pediatrics. 2017;140:e20172550.
[16] Public Health Agency of Canada. National Advisory Committee on Immunization (NACI) Canadian Immunization Guide Chapter on Inﬂuenza and Statement
on Seasonal Inﬂuenza Vaccine for 2017–2018. Ottawa, Ontario; 2017.
[17] Des Roches A, Paradis L, Gagnon R, et al. Egg-allergic patients can be safely vaccinated against inﬂuenza. J Allergy Clin Immunol. 2012;130:1213–1216, e1.
[18] 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;109:426–430.
[19] Centers for Disease Control and Prevention. Advisory Committee on Immunization Practices (ACIP) Summary Report June 24–25, 2015. Atlanta, GA: 2015.
[20] Centers for Disease Control and Prevention. Advisory Committee on Immunization Practices (ACIP) Summary Report February 24, 2016. Atlanta, GA: 2016.
[21] Committee on Infectious Diseases, American Academy of Pediatrics. Recommendations for Prevention and Control of Inﬂuenza in Children, 2015–2016.
Pediatrics. 2015;136:792–808.
[22] Kroger AT, Sumaya CV, Pickering LK, Atkinson WL. General recommendations
on immunization. MMWR Recomm Rep. 2011;60.
[23] Woo EJ. Allergic reactions after egg-free recombinant inﬂuenza vaccine: reports
to the US Vaccine Adverse Event Reporting System. Clin Infect Dis. 2015;60:
777–780.
[24] Des Roches A, Samaan K, Graham F, Lacombe-Barrios J, Paradis J, Paradis L. Safe
vaccination of patients with egg allergy by using live attenuated inﬂuenza
vaccine. J Allergy Clin Immunol Pract. 2015;3:138–139.