Use of adrenaline to manage suspected anaphylaxis following COVID-19 vaccination: An Australian retrospective cohort study

Lucy Deng; Kathryn Tapper; Deepali Thosar; Emma Goeman; Louise Baker; Stephen Adelstein; Michael Boyle; David A Brown; Louise Evans; Connie Katelaris; Frederick Lee; Jamma Li; Sanjay Swaminathan; Mark S Taylor; Melanie Wong; Nicholas Wood

doi:10.1016/j.vaccine.2023.08.024

Use of adrenaline to manage suspected anaphylaxis following COVID-19 vaccination: An Australian retrospective cohort study

Vaccine. 2023 Sep 22;41(41):5987-5993. doi: 10.1016/j.vaccine.2023.08.024. Epub 2023 Aug 24.

Authors

Lucy Deng¹, Kathryn Tapper², Deepali Thosar², Emma Goeman³, Louise Baker⁴, Stephen Adelstein⁵, Michael Boyle⁶, David A Brown⁷, Louise Evans⁸, Connie Katelaris⁹, Frederick Lee⁵, Jamma Li¹⁰, Sanjay Swaminathan¹¹, Mark S Taylor¹², Melanie Wong¹³, Nicholas Wood³

Affiliations

¹ National Centre for Immunisation Research and Surveillance, Children's Hospital at Westmead, Westmead, Australia; The University of Sydney Children's Hospital Westmead Clinical School, Westmead, Australia. Electronic address: lucy.deng@health.nsw.gov.au.
² National Centre for Immunisation Research and Surveillance, Children's Hospital at Westmead, Westmead, Australia.
³ National Centre for Immunisation Research and Surveillance, Children's Hospital at Westmead, Westmead, Australia; The University of Sydney Children's Hospital Westmead Clinical School, Westmead, Australia.
⁴ New South Wales Ministry of Health, St Leonards, New South Wales, Australia.
⁵ Department of Clinical Immunology and Allergy, Royal Prince Alfred Hospital, Camperdown, Australia; Faculty of Medicine and Health, The University of Sydney, Camperdown, Australia.
⁶ Department of Immunology, John Hunter Hospital, New Lambton Heights, Australia.
⁷ Centre for Immunology and Allergy Research, Westmead Institute for Medical Research, Westmead, Australia; Department of Clinical Immunology, Westmead Hospital, Westmead, Australia; The University of Sydney Westmead Clinical School, Westmead, Australia.
⁸ Department of Clinical Immunology, Allergy and HIV, Liverpool Hospital, Liverpool, Australia.
⁹ Department of Clinical Immunology, Allergy and HIV, Liverpool Hospital, Liverpool, Australia; Department of Immunology and Allergy, Campbelltown Hospital, Campbelltown, Australia.
¹⁰ Department of Clinical Immunology and Allergy, Royal North Shore Hospital, St Leonards, Australia; The University of Sydney Northern Clinical School, St Leonards, Australia.
¹¹ The University of Sydney Westmead Clinical School, Westmead, Australia; School of Medicine, Western Sydney University, Australia; Department of Clinical Immunology and Allergy, Western Sydney Local Health District, Australia.
¹² Department of Clinical Immunology, Allergy and HIV, Liverpool Hospital, Liverpool, Australia; Department of Clinical Immunology, Prince of Wales Hospital, Randwick, Australia; Faculty of Medicine and Health, University of New South Wales, Sydney, Australia.
¹³ Department of Allergy and Immunology, Children's Hospital at Westmead, Westmead, Australia.

PMID: 37633752
DOI: 10.1016/j.vaccine.2023.08.024

Abstract

Background: The rate of anaphylaxis following COVID-19 vaccinations is estimated to be 2-11 cases per million doses administered. However, adrenaline is occasionally used in individuals who are later diagnosed with immunisation stress-related responses, as their initial presenting signs and symptoms can appear similar to that of anaphylaxis. This study aims to describe the clinical profile of individuals who had received adrenaline following a COVID-19 vaccine and their subsequent revaccination outcomes.

Methods: We examined notifications of cases who had received adrenaline following a COVID-19 vaccine in New South Wales, Australia. The cases were classified into Brighton Collaboration Case Definition (BCCD) for anaphylaxis, their clinical presentation, management and subsequent revaccination outcomes were compared.

Results: From 22 February 2021 to 30 September 2021, there were 222 cases where adrenaline was administered. Of these, 32 (14 %) fulfilled Level 1 BCCD, 59 (27%) Level 2, 2 (1%) Level 3, 97 (44%) Level 4 and 32 (14 %) Level 5. The most commonly reported symptoms were sensation of throat closure (n = 116, 52%), difficulty breathing (n = 82, 37%) and nausea (n = 55, 25 %). Of the 176 (79%) individuals who proceeded to further vaccination, 89 (51%) received the same vaccine formulation and only 14 (8%) experienced another allergic adverse event with 9 (5%) receiving adrenaline.

Conclusion: Less than one in five individuals who received adrenaline met Level 1 BCCD criteria for anaphylaxis. Many reactions that were treated with adrenaline had little to no diagnostic certainty of anaphylaxis and in such cases repeat vaccination had a high likelihood of being tolerated. Increased awareness and education on objective signs and symptoms of anaphylaxis is required to ensure appropriate use of adrenaline.

Keywords: Adrenaline; Anaphylaxis; COVID-19; Vaccine.

MeSH terms

Anaphylaxis* / chemically induced
Anaphylaxis* / epidemiology
Australia / epidemiology
COVID-19 Vaccines* / adverse effects
COVID-19*
Epinephrine / therapeutic use
Humans
Immunization, Secondary
Retrospective Studies
Vaccination / adverse effects

Substances

COVID-19 Vaccines
Epinephrine