Suggested approach to suspected anaphylaxis to a vaccine

• Vaccine skin tests:
  • Prick test with full-strength vaccine (consider dilution if history of life-threatening reaction).
  • If prick test with full-strength vaccine negative, intradermal test with 0.02 mL vaccine 1:100.
  • NOTE: Vaccine skin tests may cause irritant (false-positive), clinically irrelevant reactions.
• Vaccine constituent skin tests/in vitro tests:
  • Prick tests with commercial extracts of egg (influenza and yellow fever vaccines), Saccharomyces cerevisiae yeast (hepatitis B vaccine and 4- and 9-valent human papillomavirus vaccines).
  • Prick test with sugared gelatin (eg, Jell-O: dissolve 1 teaspoon [5 grams] of gelatin powder in 5 mL normal saline) or in vitro assay for gelatin-specific immunoglobulin (IgE). Vaccines that contain gelatin: influenza (some brands), measles, mumps, rubella, typhoid (oral capsule), varicella, yellow fever, zoster.
  • Prick test with standardized latex extract if available. If not, obtain in vitro assay for specific IgE antibody. Vaccines that contain latex in packaging: http://www.cdc.gov/vaccines/pubs/pinkbook/downloads/appendices/B/latex-table.pdf.

¶ If fewer than the recommended number of doses have been given, consider measuring immunoglobulin G (IgG) antibodies to the immunizing agent. If the IgG level is compatible with protection from disease, consider withholding additional doses, although magnitude and duration of immunity may be less than if all doses received.

• For a vaccine where usual dose is 0.5 mL, administer graded doses of vaccine at 15-minute intervals:
  • 0.05 mL of 1:10 dilution
  • 0.05 mL of full strength
  • 0.10 mL of full strength
  • 0.15 mL of full strength
  • 0.20 mL of full strength