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Key Points
OverviewAnaphylaxis, an acute and potentially life-threatening allergic reaction, has been reported rarely following COVID-19 vaccination. These interim considerations provide recommendations on assessment and potential management of anaphylaxis following COVID-19 vaccination. Detailed information on CDC recommendations for vaccination, including contraindications and precautions to vaccination, can be found in the Clinical Considerations for Use of COVID-19 Vaccines Currently Authorized in the United States. Patients should be screened prior to receipt of each vaccine dose, and those with a contraindication should not be vaccinated. A COVID-19 prevaccination questionnaire [6 pages] is available to assist with screening. Personnel, medications, and supplies for assessing and managing anaphylaxisHealthcare personnel who are trained and qualified to recognize the signs and symptoms of anaphylaxis, as well as administer intramuscular epinephrine, should be available at the vaccination location at all times. Vaccination locations that anticipate vaccinating large numbers of people (e.g., mass vaccination clinics) should plan adequate staffing and supplies (including epinephrine) for the assessment and potential management of anaphylaxis. The following emergency equipment should be immediately available for the assessment and management of anaphylaxis.Medications and supplies for assessing and managing anaphylaxis
*COVID-19 vaccination locations should have at least 3 doses of age-appropriate epinephrine available at all times, and the ability to quickly obtain additional doses to replace supplies after epinephrine is administered to a patient. Locations that are administering COVID-19 vaccines to children <12 years should have age-appropriate supplies, including age-appropriate epinephrine dosing. People with a history of anaphylaxis who carry an epinephrine autoinjector could be reminded to bring it to their vaccination appointment. Detailed information on storage, handling, administration, and dosage considerations is available in the package inserts for epinephrine (e.g., EpiPen®). Expired epinephrine or epinephrine that appears to be in unacceptable condition (per the manufacturer’s package inserts) should be replaced. †Antihistamines may be given as adjunctive treatment but should not be used as initial or sole treatment for anaphylaxis. Additionally, caution should be used if oral medications are administered to people with impending airway obstruction. ‡Either an automated or a manual blood pressure monitor, with appropriate cuff sizes, is acceptable. If a manual blood pressure monitor is used, a stethoscope should also be available. Post-vaccination observation periodsProviders should consider observing all vaccine recipients for 15 minutes after vaccination for syncope, per the Advisory Committee on Immunization Practices’ General Best Practice Guidelines. Additionally, providers should consider observing people with the following medical histories for 30 minutes after COVID-19 vaccination to monitor for allergic reactions:
Early recognition of anaphylaxisBecause anaphylaxis requires immediate treatment, diagnosis is primarily made based on recognition of clinical signs and symptoms. Signs and symptoms in adults and children include:
Anaphylaxis should be considered when signs or symptoms are generalized (i.e., if there are generalized hives or more than one body system is involved) or are serious or life-threatening in nature, even if they involve a single body system (e.g., hypotension, respiratory distress, or significant swelling of the tongue or lips). Symptoms of anaphylaxis often occur within 15-30 minutes of vaccination, though it can sometimes take several hours for symptoms to appear. Early signs of anaphylaxis can resemble a mild allergic reaction, and it is often difficult to predict whether initial, mild symptoms will progress to become an anaphylactic reaction. In addition, symptoms of anaphylaxis might be more difficult to recognize in people with communication difficulties, such as long-term care facility residents with cognitive impairment, those with neurologic disease, or those taking medications that can cause sedation. Not all symptoms listed above are necessarily present during anaphylaxis, and not all patients have skin reactions. More information on potential characteristics of allergic reactions, vasovagal reactions, and vaccine side effects following COVID-19 vaccination can be found in the Appendix. If anaphylaxis is suspected, administer epinephrine as soon as possible, contact emergency medical services, and transfer patients to a higher level of medical care. In addition, instruct patients to seek immediate medical care if they develop signs or symptoms of an allergic reaction after their observation period ends and they have left the vaccination location. If anaphylaxis is suspected, take the following steps:
Considerations for anaphylaxis management in special populationsChildren <12 YearsFacilities providing COVID-19 vaccines for children aged <12 years should ensure they have age and size appropriate emergency supplies on hand. Symptoms of anaphylaxis in children are similar to those seen in adults. Children <25 kg (55 lbs) require lower dosing of epinephrine for management of anaphylaxis. Pediatric autoinjectors are available in 0.15mg and 0.30 mg doses. Older adults, including long-term care facility residentsThere are no contraindications to the administration of epinephrine for the treatment of anaphylaxis. Although adverse cardiac events, such as myocardial infarction or acute coronary syndrome, have been reported in some patients who received epinephrine for treatment of anaphylaxis (particularly among older adults with hypertension and/or atherosclerotic heart disease), epinephrine is the first-line treatment for anaphylaxis. It is important that locations providing vaccination to older adults, including long-term care facility residents, have staff members available who are able to recognize the signs and symptoms of anaphylaxis. This will help not only to ensure appropriate and prompt treatment for patients with anaphylaxis, but also to avoid unnecessary epinephrine administration to patients who do not have anaphylaxis. Pregnant peoplePregnant people with anaphylaxis should be managed in the same manner as non-pregnant people. As with all patients with anaphylaxis, they should be transported to a medical facility where they and their fetus can be closely monitored to ensure adequate perfusion. Homebound people requiring home vaccination servicesHomebound people who might be at increased risk for anaphylaxis following vaccination (i.e., people with a precaution to vaccination or those with a history of anaphylaxis due to any cause) should consider whether they could be vaccinated in a setting where medical care is immediately available if they experience anaphylaxis following vaccination. If home vaccination is the only option for these people and, through risk assessment, it is determined that the benefits of vaccination outweigh the potential risk for anaphylaxis, home vaccination providers should ensure they are able to manage anaphylaxis. This includes appropriate screening; post-vaccination observation; medications and supplies; staff qualifications for recognition and treatment of anaphylaxis; ability to call for EMS; and location in an area where EMS is available. Patient counselingPatients who experience a severe allergic reaction (e.g., anaphylaxis) after a dose of a COVID-19 vaccine should be instructed not to receive additional doses of the same type vaccine; if the dose received was an mRNA COVID-19 vaccine, the patient should not receive additional doses of either Pfizer-BioNTech or Moderna COVID-19 Vaccine. In addition, patients may be referred to an allergist-immunologist for appropriate work-up and additional counseling. Reporting anaphylaxisAnyone can report any adverse events, including anaphylaxis, that occur in a recipient following COVID-19 vaccination, to the Vaccine Adverse Event Reporting System (VAERS). Vaccination providers administering a COVID-19 vaccine that is under Emergency Use Authorization are required by the Food and Drug Administration to report vaccine administration errors, serious adverse events, cases of Multisystem Inflammatory Syndrome, and cases of COVID-19 that result in hospitalization or death. Reporting is also encouraged for any other clinically significant adverse event, even if it is uncertain whether the vaccine caused the event. Refer to the VAERS website or call 1-800-822-7967 for more information on how to submit a report to VAERS. In addition, CDC has developed a new, voluntary, smartphone-based tool, called “v-safe,” that uses text messaging and web surveys to provide patients with near real-time health check-ins after they receive a COVID-19 vaccination. CDC/v-safe call center representatives will follow up on reports of medically significant health impacts to collect additional information and complete a VAERS report. Learn more about v-safe on CDC’s website. ReferencesClinical Considerations for Use of COVID-19 Vaccines Currently Authorized in the United States Lieberman P, et al. “Anaphylaxis: A practice parameter update.” Annals of Allergy, Asthma & Immunology 2015; 115(5): 341-384. doi: 10.1016/j.anai.2015.07.019. Shaker MS, et al. “Anaphylaxis—a 2020 practice parameter update, systematic review, and Grading of Recommendations, Assessment, Development and Evaluation (GRADE) analysis.” Journal of Allergy and Clinical Immunology 2020;145(4):1082-1123. doi: 10.1016/j.jaci.2020.01.017. Sicherer SH, Simons FER; SECTION ON ALLERGY AND IMMUNOLOGY. Epinephrine for First-aid Management of Anaphylaxis. Pediatrics. 2017;139(3):e20164006. doi:10.1542/peds.2016-4006 Appendix: Potential characteristics of allergic reactions, vasovagal reactions, and vaccine side effects following COVID-19 vaccinationIn patients who experience post-vaccination symptoms, determining the etiology (including allergic reaction, vasovagal reaction, or vaccine side effects) is important to determine whether a person can receive further doses of the vaccine. The following table of signs and symptoms is meant to serve as a resource but might not be exhaustive, and patients might not have all signs or symptoms. Vaccination providers should use their clinical judgement when assessing patients to determine the diagnosis and management.
Note: Severe allergic reactions include:
Non-severe allergic reactions may include:
Previous UpdatesRevisions made Feb 11, 2022
Revisions made Nov 3, 2021
Revisions made March 3, 2021
Revisions made February 10, 2021
What drug is most commonly prescribed during an anaphylaxis reaction?Epinephrine — Epinephrine is the first and most important treatment for anaphylaxis, and it should be administered as soon as anaphylaxis is recognized to prevent the progression to life-threatening symptoms as described in the rapid overviews of the emergency management of anaphylaxis in adults (table 1) and children ...
What drugs are used to treat anaphylactic shock?Treatment. Epinephrine (adrenaline) to reduce the body's allergic response.. Oxygen, to help you breathe.. Intravenous (IV) antihistamines and cortisone to reduce inflammation of the air passages and improve breathing.. A beta-agonist (such as albuterol) to relieve breathing symptoms.. |