Case studies: post-vaccination care

CASE 1: Egg allergy

Q: AG is a 29-year-old woman who is reluctant to get a flu shot and does so only because her employer requires it. When reading the screening and consent form, she mentions that she is allergic to eggs and that the flu vaccine contains eggs. She can tolerate foods containing eggs, such as bread and cakes, but has suffered from hives and itching after eating scrambled eggs. What should the pharmacist advise?

A: Most flu vaccines are grown in eggs and contain small amounts of egg protein called ovalbumin.1 Cell culture (Flucelvax Quadrivalent) and recombinant (Flublok Quadrivalent) influenza vaccines do not contain eggs at all. About 0.2% of adults and 1.3% of children are allergic to eggs. It should be noted that in describing his reaction, AG said he experienced hives and itching after consuming lightly cooked eggs. Studies have been conducted to assess the safety of influenza vaccines in people with egg allergies. All of the egg-allergic people in the study, even those with a history of anaphylaxis, received the trivalent inactivated influenza vaccine without serious reactions. Because AG has no history of angioedema or other serious egg reactions, the CDC recommends that these patients receive any drugstore-approved form of influenza vaccine. If AG had reported a history of severe reactions to eggs, she should have been instructed to receive the flu shot at an inpatient or outpatient medical center under the supervision of a provider, not at a pharmacy. If AG has an allergic reaction to influenza vaccine with angioedema and/or respiratory distress, the emergency medical system should be activated and a dose of 0.3 mg epinephrine given intramuscularly, using a pre-measured or pre-filled syringe or auto-injector should be administered into the mid-thigh while awaiting emergency medical attention.2.3

CASE 2: Syncope

Q: JG is a 17 year old girl who came to the pharmacy with her mother to get vaccinated against HPV. JG is afraid of needles and vaccines and says he has heard of teenagers fainting after receiving the human papillomavirus (HPV) vaccine. She asks about syncope after vaccination and how to prevent and treat it. What should the pharmacist tell him?

A: Syncope, or fainting, is caused by A decreased blood flow to the brain that results in temporary loss of consciousness. Although syncope can occur with any vaccine, it is more common after HPV, meningococcal, tetanus, diphtheria, and pertussis vaccines. In addition, syncope is reported more frequently (62%) in adolescents aged 11 to 18 years. Although patients recover almost immediately from syncope, the potential injuries associated with fainting and falls are of greater concern. According to 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 them about the procedure or simply comfort them and consider providing them with a drink or snack. Most importantly, preventing syncope-related complications and head injuries requires preparation before vaccination and prompt action in the event of syncope. Make sure the patient is lying down or sitting up during the vaccination. Monitor patients closely for 15 minutes after vaccination. If syncope occurs, have the patient lie flat and keep the airway open. Apply a cool, damp cloth to face and neck and elevate feet. Closely monitor the patient until fully recovered and activate medical emergency 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 flu and pneumococcal shots. She asks to speak to the pharmacist, as she had read about adverse effects of intramuscular vaccines, including shoulder bursitis or subdeltoid bursitis. What information must the pharmacist provide?

A: Subdeltoid bursitis following intramuscular (IM) vaccination, also known as vaccine-related shoulder injury (SIRVA), presents as shoulder pain and amplitude limited movement after IM injection, due to an anti-inflammatory reaction. Patients with SIRVA experience pain at rest that worsens with movement. A retrospective study of 3 million people who received the flu vaccine showed 16 cases of subdeltoid bursitis within 2 days of receiving the vaccine. SIRVA can be treated with anti-inflammatory medications, ice, over-the-counter or prescription pain relievers, physical therapy, and rest.6

The correct anatomical location for an IM injection is in the lower two-thirds of the deltoid, and the appropriate needle length should be selected based on the patient’s muscle mass to reduce the risk of injecting too deep, at beyond the muscle and into the bursa. Patients who underwent SIRVA were rated as having received the injection higher than recommended. The CDC has developed and disseminated guidelines for IM vaccine administration technique and selection of appropriate needles.6.7

CASE 4: COVID-19 vaccine

Q: JS is a 42-year-old woman receiving her second dose of the Moderna COVID-19 vaccine. She was initially hesitant to get vaccinated, but her employer insisted on it. JS said she felt fine after the first dose, apart from being tired the night of the vaccination. She is nervous about the second dose because she has heard and read mixed reports of patient reactions. JS asks about personal care after this dose. What information can the pharmacist provide?

A: Some people have adverse reactions (ARs) from COVID-19 vaccines, and JS is right to prepare for self-care to prevent and manage ARs. On a positive note, the ARs reported are symptoms of enhanced immunity and protection. Local AEs reported at the injection site include pain, redness, and swelling. Systemic reactions include chills, fatigue, fever, headache, or nausea. Over-the-counter acetaminophen and ibuprofen are recommended to treat AEs unless otherwise directed by a doctor. It is not recommended that patients take either of these agents prior to vaccination. Non-pharmacological recommendations for local reactions include applying a cold, damp washcloth to the injection site and moving the injected arm slightly after vaccination. Non-pharmacological recommendations for systemic reactions are to drink plenty of water and wear loose clothing to reduce discomfort from fever.8

About the authors

Ammie Patel, PharmD, BCACP, is Clinical Assistant Professor of Pharmacy Practice and Administration at Ernest Mario School of Pharmacy at Rutgers, State University of New Jersey at Piscataway, and 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 the Ernest Mario School of Pharmacy at Rutgers, State University of New Jersey at Piscataway, and clinical pharmacist in care transition at Morristown Medical Center in the New Jersey.

References

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. Influenza vaccine and egg allergy sufferers. 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 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 of subdeltoid bursitis after influenza vaccination: a population-based cohort study. Ann Medical Intern. 2020;173(4):253-261. doi:10.7326/M19-3176

7. Administration of vaccines. 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

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