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Pre-vaccination allergy testing with COVID-19 mRNA vaccines predicts tolerance
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  • Florian Stehlin,
  • Rima Mahdi-Aljedani,
  • Loris Canton,
  • Véronique Monzambani-Banderet,
  • Alix Miauton,
  • Cedric Girard,
  • Kevin Kammermann,
  • Sylvain Meylan,
  • Camillo Ribi,
  • Thomas Harr,
  • Daniel Yerly,
  • Yannick Muller
Florian Stehlin
Centre Hospitalier Universitaire Vaudois

Corresponding Author:florian.stehlin@chuv.ch

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Rima Mahdi-Aljedani
Centre Hospitalier Universitaire Vaudois
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Loris Canton
Centre Hospitalier Universitaire Vaudois
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Véronique Monzambani-Banderet
Centre Hospitalier Universitaire Vaudois
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Alix Miauton
Policlinique Médecine Tropicale Voyages et Vaccinations Unisanté Lausanne
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Cedric Girard
Centre Hospitalier Universitaire Vaudois
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Kevin Kammermann
Adverse Drug Reactions - Analysis & Consulting (ADR-AC) GmbH Bern Switzerland
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Sylvain Meylan
Centre Hospitalier Universitaire Vaudois
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Camillo Ribi
Centre Hospitalier Universitaire Vaudois
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Thomas Harr
Hopitaux Universitaires Geneve
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Daniel Yerly
Adverse Drug Reactions - Analysis & Consulting (ADR-AC) GmbH Bern Switzerland
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Yannick Muller
Centre Hospitalier Universitaire Vaudois
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Abstract

Background: The newly developed mRNA-based COVID-19 vaccines can provoke anaphylaxis, possibly induced by polyethylene glycol (PEG) contained in the vaccine. The management of persons with a history of PEG allergy, or with an allergic-like reaction after the first dose remains to be defined.  Methods: We studied two cohorts of individuals: one pre-vaccination, the second post-vaccination. Skin testing was performed with COVID-19 mRNA vaccines. Upon negative skin test, a two-step (10%-90%) vaccination protocol was performed. Positive skin tests were confirmed with basophil activation tests (BAT). Vaccine-sensitized patients were offered a five-step induction protocol. Results: We identified 187 patients with high-risk profiles for developing anaphylaxis. In parallel, among 385’926 doses of vaccine, 87 allergic-like reactions were reported to our division for further investigations: 18/87 (21%) were consistent with anaphylaxis, 78/87 (90%) were female, and 47/87 (54%) received the BNT162b2 mRNA vaccine. Vaccine skin tests were negative in 96% and 76% in the pre- and post-vaccination cohorts, respectively. A two-step vaccination was tolerated in 232/236 (98%) of individuals with negative tests. Four individuals experienced acute asthma exacerbation during the two-step challenge. Vaccine-positive skin tests were consistently confirmed by BAT; CD63 and CD203c expression was selectively inhibited with ibrutinib, suggesting an IgE-dependent mechanism. Finally, 13 sensitized patients were successfully vaccinated with a five-step vaccination protocol. Conclusion: A two-step 10%-90%-vaccination protocol can be safely administered upon negative skin testing. Yet, it should be delayed in individuals with poorly controlled asthma. Importantly, mRNA vaccine sensitized individuals may receive a five-step vaccination protocol.