Q. My 4 year-old had anaphylaxis after chickenpox, DTP, polio, and MMR vaccinations at the same time. Immediately, in our pediatrician’s office, he complained of his throat hurting, was sneezing, drooling , threw up and had red, itchy skin and trouble breathing. My son doesn’t have hay fever, and we don’t have a family history of allergies. Do you have any idea what could be causing these reactions?

A. Your child’s reactions may be related to gelatin, which is added as a stabilizer to some vaccines - and found in both MMR and chickenpox vaccines. The possibility of gelatin allergy will be evaluated by the allergist, who can perform either blood testing to look for a specific antibody to gelatin, or skin prick testing to a substance containing gelatin.

Q. My 4 year-old son recently had anaphylaxis after the following vaccinations were given at the same time: chickenpox, DTP, polio, and MMR. Immediately after these immunizations in our pediatrician’s office, he complained of his throat hurting, was sneezing, drooling , threw up and had red, itchy skin and trouble breathing. He was taken by ambulance to the ER, and treated with shots including epinephrine. In the past, he has had drooling and vomiting after eating a piece of protein chocolate bar and when taking his gummy vitamins, and complained of his throat hurting after eating marshmallows.

We are scheduled to see an allergist. My son doesn’t have any hay fever, and we don’t have a family history of allergies. Do you have any idea what could be causing these reactions?

A. From what you mention, your child’s reactions may be related to gelatin, which is added as a stabilizer to some vaccines - and found in both the MMR (Measles Mumps Rubella) and chickenpox (varicella) vaccines. Yellow fever vaccine and rabies vaccine also contain gelatin, but are not part of the routine childhood vaccination schedule. Neomycin, an antibiotic, is another ingredient in some vaccines which can be related to allergic reactions; this may also result in a reaction if used with topical application (as in "triple antibiotic" antibacterial skin creams, sold over-the-counter). In your child’s case, there is the additional information of reactions with foods that typically contain gelatin, leading us to suspect this ingredient in particular. The possibility of gelatin allergy will be evaluated by the allergist, who can perform either blood testing to look for a specific antibody to gelatin, or skin prick testing to a substance containing gelatin. Skin testing to each vaccine can be also done by the allergist, to determine which one caused the reaction. From the list of ingredients, the common culprit in the vaccine(s) and in the foods can then be identified. Your child should have self-injectable epinephrine prescribed for use in case of life-threatening allergic reactions/anaphylaxis, as you have described with the vaccine and food reactions. Given the circumstances, any further vaccinations should be held - and foods containing gelatin avoided - until the exact cause of reactions has been determined.

Q. I am a 66 year-old man who was recently discharged from the hospital after a prolonged and resistant pneumonia. After seeing an allergy/immunology doctor for an evaluation of a possible immune deficiency problem, I had some lab studies done. A certain test called gamma globulin came back in the low normal range but some of the other tests were not quite normal. The allergist recommended that I have a Pneumovax (pneumococcal vaccine) and a tetanus/diptheria/pertussis vaccination and then have some repeat blood tests. Is it really necessary to have both of these vaccines and how do they help to identify if I have an immune problem?

A. Someone with an immune deficiency is very likely to have low normal or even normal gamma globulin levels but still have an inability to make antibodies to specific organisms, such as pneumococcus, a bacteria which can cause pneumonia. The blood work you had taken likely showed your allergist that you lacked proper antibodies to specifically fight pneumococcal diseases and that you lacked protection against tetanus and/or diphtheria. The absence of these antibodies does not in itself mean that you have an immune problem as you may have lost the immunity from the diphtheria/tetanus/pertussis that you had as a child and likewise, may indicate that you have not been exposed to many of the pneumococcal organisms that were tested in the blood. However, you need protection against all these organisms - a recommendation for all adults over 65!

By receiving the vaccines that your physician has recommended, you will likely gain that protection. And by repeating the blood tests in 4 weeks following the vaccinations, your allergist will know if your immune system is functioning properly. You really need both vaccinations for protection and to gain necessary information about your immune system. If there is an inadequate response to these vaccines, further immune studies and treatment, possibly long-term, may be required. These vaccines can be administered at the same time. In terms of cost, Medicare will cover the cost of the blood tests and the Pneumovax but will likely not cover the cost of the Tdap at this time (but that might change soon). I would suggest that you follow your allergist’s advice and obtain the vaccines and then the blood tests 4 weeks later.

Q. I thought the influenza vaccine changed each year. My nurse looked at this year’s influenza vaccine and found it has H1N1 again. Isn’t that swine flu, and why do we still need the same virus?

A. Your nurse is correct there is one strain of H1N1 (also known as swine flu) in this year’s vaccine. H1N1 is a subtype of Influenza A that has caused roughly half of all human influenza infections we’ve seen in the past several years. Influenza viruses are identified by two surface proteins: Hemagglutin (H) and Neuramidase (N). The strains H1, H2 and H3, and N1 and N2 are found in people. Different strains are found in birds and pigs. The strains found in animals can be spread to humans, as seen in the recent pig flu found in some human contacts. If a sufficient genetic shift occurs in an animal virus strain, it can then be transmitted person to person. Scientists closely monitor the strains infecting humans as well as animals, as crossover to humans may signal the next pandemic influenza. Yes, the human influenza strains do shift from year to year but it is very rare that all three strains in an influenza vaccine change in any given year. Therefore you will see repeating strains if you watch the vaccines' contents.

This year’s influenza vaccine does contain one H1N1 strain. This is the same pandemic strain that emerged in 2009. It also contains a H3N2 strain that differs from last year’s vaccine. The sole Influenza B strain contained in the 2012-2013 influenza vaccine is also different from last year. People need a yearly influenza vaccine for two reasons: immunity to influenza decreases over time, and the vaccines usually contain new strains each year.

Q. My nurse looked at this year’s respiratory flu vaccine and found it has H1N1 already in it — isn’t that the same as swine flu?

A. She’s right! The terminology is a little confusing but here’s a refresher: H1N1 is a subtype of Influenza A that has caused roughly half of all human flu infections we’ve seen in the past several years. H1N1 viruses are identified by two surface proteins: Hemagglutin (H) and Neuramidase (N). The strains H 1, 2 and 3, and N 1 and 2 are found in people - a lot more strains are found in birds and pigs. Your nurse is right. This year’s respiratory flu does contain several H1N1 strains. But this year’s "swine flu" or H1N1 flu results from reshuffling of four different flu viruses – North American swine influenza, North American avian influenza, human influenza, and swine influenza virus usually found in Asia and Europe. Maybe we do get some general crossover protection with the regular respiratory flu shot or mists — but you can’t get specific protection with anything but the new additional flu shots.

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