CASE SERIES OF ANAPHYLAXIS FOLLOWING IMMUNISATION OF PHASE 1 NATIONAL COVID-19 VACCINATION PROGRAM IN INSTITUT JANTUNG NEGARA

Abstract

INTRODUCTION
Institut Jantung Negara participated in Phase 1 National COVID-19 Vaccination Program for frontliners from 1^st March 2021. All acute Adverse Events Following Immunization (AEFI) that required treatment were managed in the Emergency Department (ED). We describe 3 cases of anaphylaxis after receiving Comirnaty^® vaccine.
CASE 

Case 1 had history of bronchial asthma with multiple allergies including seafood anaphylaxis. He developed severe bronchospasm, restlessness, hypoxia and tachycardia after the 1^st vaccine dose. He required multiple doses of intramuscular (IM) adrenaline, nebulised salbutamol and intravenous (IV) hydrocortisone and subsequently, adrenaline infusion. His treatment in the coronary care unit (CCU) included magnesium sulphate, ketamine, aminophylline and intermittent non-invasive ventilation. He had recurrent episodes of severe bronchospasm which led to prolonged length of stay of 14 days. Case 2 had history of multiple medication allergies, who developed choking sensation, tachycardia and feeling of impending doom after the 2^nd vaccine dose. She was treated with IM Adrenaline boluses, IV hydrocortisone and also required adrenaline infusion. She was admitted to CCU for  4 days. Case 3 had history of generalised rash after the 1^st vaccine dose which was not disclosed prior to the 2^nd dose.  She developed severe bronchospasm and was given IM Adrenaline, nebulised salbutamol and IV hydrocortisone.

RESULTS

All 3 cases were discharged well from the hospital. Case 1 & 2 were referred to an Immunologist on discharge for full allergy assessment. Case 1 carries an adrenaline auto-injector for future incidents.

DISCUSSION

Common presentations to ED following immunisation were palpitations and giddiness.  Delayed reactions were mostly self-limiting viral-like illness. 3 cases of anaphylaxis were briefly assessed in Sick Bay at the Vaccination Center and immediately sent to ED for management. The 3^rd edition Clinical Guidelines on Covid-19 Vaccination in Malaysia quotes the Comirnaty^® vaccine anaphylaxis rate range from 4.7 cases/million doses in US to 24 cases/million doses in Japan. As of 16/6/2021, Malaysia’s anaphylaxis incidence was 6.6 cases/million doses. 

CONCLUSION

Anaphylaxis is a rare but serious AEFI to Comirnaty^® vaccine. Prompt recognition of anaphylaxis and immediate treatment with adrenaline are key in management of this unintended event.