Send letter to journal:
Re: MMR vaccine in children allergic to egg

Dear Editor

Two reviews of MMR vaccine and egg allergy have recently been published. [1, 2] One appears in the Royal College of Paediatrics and Child Health's own journal (Archives of Diseases in Childhood),[1] the other has been endorsed by the Committee on Infection and Immunisation of the Royal College of Paediatrics and Child Health.[2] The two articles differ in their recommendations of which children should be given MMR under supervision in hospital.

Which of these expert opinions should paediatricians and general practitioners follow? Were the authors of the two articles aware of each others conclusions? Could the editorial boards of the two journals (which have members common to both) not have informed the authors?

These recommendations also differ from Department of Health advice,[3] which also differs from that given by the Health Education Authority.[4] This debate might be settled if a consensus can be agreed and published in the next edition of Immunisation against Infectious Disease.[3]

In the mean time a pragmatic approach is needed. That is to offer MMR under supervision in hospital to children who have had a severe allergic reaction to egg and to children whose general practitioners, practice nurses or parents are unhappy for them to be given MMR elsewhere.

This letter has also been sent to BMJ.

F Andrew I Riordan
Consultant Paediatrician Dept of Child Health
Birmingham Heartlands Hospital
BIRMINGHAM B9 5SS, UK

References

1. Lakshman R, Finn A. MMR vaccine and allergy. Arch Dis Child 2000;82:93-95

2. Khakoo GA, Lack G. Recommendations for using MMR vaccine in children allergic to eggs. BMJ 2000;320:929-932

3. Salisbury DM, Begg NT eds. Immunisation against infectious disease. London: HMSO 1996;38:141

Send letter to journal:
Re: Re: MMR vaccine in children allergic to egg

Dear Editor:

We note Riordan's response to our editorial on the issue of MMR vaccine and allergy[1] and the recommendations put forward by Khakoo and Lack[2] on this topic. While we agree that conflicting advice creates confusion, we cannot agree with his proposed "pragmatic approach". This amounts to a pointless waste of time and resources - greater than that proposed by anyone else to date - which will simply stoke up unfounded concerns about this vaccine while diverting people from the important necessity to prepare themselves to tackle cases of severe anaphylaxis which, on the rare occasions that they occur, will continue to do so in community clinic settings.

1. Lakshman R, Finn A. MMR Vaccine and Allergy. Arch Dis Child 2000;82:93-95
2. Khakoo GA, Lack G. Recommendations for using MMR vaccine in children allergic to eggs. BMJ 2000;320:929-932

R Lakshman
Research Fellow

Send letter to journal:
Re: Re: MMR vaccine in children allergic to egg

Dr Riordan ask which expert opinion to follow. The answer surely lies in reading the papers carefully, seeking out any key references quoted and deciding for oneself who has provided the best evidence. This should be the case for all guidelines, but we know that they are often absorbed undigested, which is one reason why ADC erects fairly firm barriers to their publication. Lakshman and Finn's paper was commissioned by the editors as a leading article because, as practising paediatricians, we recognised that all of us have problems responding logically to requests to immunise children in hospital.

When we commissioned this paper we did not know that a college committee was embarking on an enquiry; we learned this only after our leading article had been peer reviewed and was set up for publication. Editors of ADC have long been saddened that many of our readers, including members and fellows of the RCPCH, prefer first to submit their papers elsewhere; we realise, of course, that the artificial constraints of the research assessment exercise result in some authors needing to collect Brownie points by publishing in journals with a high impact factor even if their research thereby reaches an inappropriate readership. In this sense, the BMJ is our competitor not our partner which is why editors do not tell each other what they have in the pipeline.

I realise that this cannot have been the case in this instance as the BMJ copied Khakoo and Lack's paper from the specialist journal in which it originally appeared (which probably has a lower score than ADC and read by far fewer paediatricians).

Dr Riordan suggests seeking a consensus. Far better would be to undertake a full literature search of RCTs and subject it to a systematic review. The days of guidelines by GOBSAT* are over. At this year's annual scientific meeting of the RCPCH the journal and the college's quality of practice committee have forged a working relationship that should leave our readers less confused in future.

Harvey Marcovitch Editor in Chief

Send letter to journal:
Re: Controversy about MMR vaccinations in children with or without egg allergy

Dear Editor,

According to our studies 1803 children allergic to egg have been safely received the MMR vaccine. Systemic reactions were present only in 0.1% of cases and untoward reactions only in 1.7% cases (p = 0.0001).[1] No child vaccinated by us has manifested immediate reactions.[1] According to Sampson et al[2] the MMR vaccine is safe in such children, evaluating on the basis of confidence intervals (95%) that 97.5% of children can be safely vaccinated. The reactions reported by various authors were provoked by the gelatin present in plasma-expanders, which provokes reactions in 0.07-0.2% of cases and neomycin of which MMR vaccine contains 25 mg.[1]

In 47 non egg-allergic children a case of anaphylactic shock was due to gelatin, while the skin reactions to neomycin are more frequent, thus explaining the prevalence of urticarial manifestations in the vaccinated children. However the risk of untoward reactions in non egg-allergic children, is almost non existent, being = 0.00005%.[1] Two recent works increase the confusion, because one[3] suggests to perform MMR vaccinations in all children under controlled conditions in hospital, and the other[4] restrict these precautions to children with cardiorespiratory responses to egg and/or chronic asthma. No one gives suggestions about possible reactions to gelatin and/or neomycin.

We judge these conclusions[3, 4] allarmistic, and suggest that no guideline should prevent MMR vaccination in children. Obviously we recommend to vaccinate in the hospital all the children who have manifested severe, life-threatening reactions to egg. The door remains open for children who have had anaphylactic reactions to gelatin or neomycin: give MMR vaccine in hospital. Adrenaline at hand could be a useful addition.

References

1. Cantani A, Serra A, Arcese G, Lucenti P. Allergic reactions to MMR vaccines in egg- and not-egg-sensitive children: a continuing controversy. Pediatr Asthma Allergy Immunol 1995;9:7-14.

2. James JM, Burks AW, Roberson PK, Sampson HA. Safe administration of the measles vaccine to children allergic to eggs. N Engl J Med 1995;332:1262-6.

3. Lakshman R, Finn A. MMR vaccine and allergy. Arch Dis Child 2000;82:93-5

4. Khakoo GA, Lack G. Recommendations for using MMR vaccine in children allergic to eggs. BMJ 2000;320:929-32.

Send letter to journal:
Re: Re: Controversy about MMR vaccinations in children with or without egg allergy

Dear Editor

Professor Cantani's[1] experience is very similar to what we found in our review[2] - that egg allergic children do not appear to be at any greater risk to severe allergic reactions with MMR vaccine.

In our review, we do not advocate hospitalisation of children with egg allergy for MMR immunisation; on the contrary we suggest that all children (including children with egg allergy) can be immunised with MMR vaccine in the community.

Since anaphylaxis is an extremely rare and unpredictable consequence of any vaccination, we suggested in our review that all children (not just children with egg allergy) must receive all vaccinations (not just MMR) in a place which is equipped to deal with anaphylaxis- by this we did not mean a hospital - and they must be observed for sufficient time after the injection to make sure they are well. As Professor Cantani mentions, many of the reactions to the MMR may be due to the gelatin or neomycin. It is generally agreed that MMR vaccine is contraindicated in children who have had severe systemic reactions to either gelatin or neomycin.

References

1. Cantani A, Serra A, Arcese G, Lucenti P. Allergic reactions to MMR vaccines in egg- and not-egg-sensitive children: a continuing controversy. Pediatr Asthma Allergy Immunol 1995;9:7-14.

Send letter to journal:
Re: Recommendations or guidelines regarding MMR vaccination in children allergic to egg should be clear

Dear Editor

I thank doctors Lakshman and Finn for their kind reply, and recognise that my use of the word "hospital" has given rise to a misunderstanding. My letter was based on the analysis the authors have made, not in the ADC article,[1] but in their eLetter to BMJ.[2]

They wrote:
(1) immunisation with any vaccine in any child always carries a risk of potentially fatal anaphylaxis
(2) and must always be carried out in settings where personnel equipped to recognise and manage it are present
(3) annual updates in recognition and management of anaphylaxis for personnel involved in immunisation are desirable
(4) essential equipment - adrenaline, airway, Ambu bag with masks and a telephone to call for emergency help should always be to hand and regularly checked
(5) infants and children must be observed for at least 30 minutes after the injection to confirm that they are completely well before they leave the premises".

According to my interpretation, all these prerequisites are rarely to be found in the offices of paediatricians.

(1) I do not know how many paediatricians are equipped to recognise and manage anaphylaxis, considering that they usually operate not in "settings", but in their offices
(2) How many paediatricians are expert in the treatment of such reactions, and have adrenaline ready in the same tray as the vaccine?
(3) annual updates for paediatricians are helpful, however the authors prefer annual updates for personnel involved in immunisation, but I do not know in which specific place they are to be held, according to the authors
(4) paediatricians' offices are rarely equipped with Ambu masks, they are not reanimators or expert in resuscitation manoeuvres, in addition, adrenaline should also be kept in a refrigerator, and is no longer valid after 24-36 months; from an economical point of view, it is not convenient to store drugs used perhaps once in a year
(5) observation of vaccinated infants and children for at least 30 minutes is the easiest procedure to follow in a paediatrician's office.

Can the "settings where personnel equipped, etc", be paediatricians' offices? or can the "settings" be interpreted as "hospital-like premises", where annual discussions are to be held, where adrenaline is used continuously, and personnel with Ambu masks are operating? No such precautions were applied during MMR vaccinations in egg-allergic children made by us, and as far as I know, in the rest of about 1800 children previously cited by me.[3] I repeat, such precautions are valid only with children with severe reactions to egg documented with challenge tests. However to extend these recommendations[2] to all children subjected to MMR vaccine appears to be not practical as it would eliminate all programs in which vaccination is performed by nurses without doctors in attendance, as occurs in most Developing World countries and in almost all public health clinics First World countries.[3]

References

1. Lakshman R, Finn A. MMR vaccine and allergy. Arch Dis Child 2000;82:93-5

2. Lakshman R, Finn A. MMR Vaccine and Egg Allergy. BMJ [eLetter] 31 March 2000