Contrary to advice from an antivaxxer, claiming a history of anaphylaxis after vaccination will not guarantee a medical exemption

If there’s one thing I’ve learned about the antivaccine movement, it’s that honesty is not its forte. As long ago as 2007, I was pointing out how leaders of the antivaccine movement were providing strategies to parents to lie about their religion in order to obtain religious exemptions to school vaccine mandates. More recently, with the much welcomed passage of laws eliminating nonmedical school vaccine mandates, such as SB 277 in California, the dishonesty shifted to claiming medical exemptions for conditions for which they are not needed and that science doesn’t support; e.g., family history of autism, family history of autoimmune diseases, and the like. Sadly, this dishonesty was perpetrated by antivaccine physicians, who got in on the grift of selling bogus medical exemption letters. However, just the other day, I saw an antivaxxer advocating lying about something I’d never seen an antivaxxer advocate lying about before, at least not that I recall. Over at the blog of a certain antivaxxer who’s occasionally appeared in the comments here, I saw a post, How to avoid mandatory vaccination. And what strategy did this antivaxxer advocate for avoiding school vaccine mandates? To lie about a history of an anaphylactic reaction to vaccination!

I kid you not:

The CDC provides a list of contraindications for every vaccine. A “contraindication” is a factor or condition that means a drug or treatment must not be used. It is the most powerful reason for not getting a vaccine, stronger than other reasons for a medical exemption. Other reasions for medical exemption (e.g. immune deficiency, or presence other disease such as cancer) can be debatable, depending on severity, and ultimately leave the vaccination decision to the patient. A contraindication however affirmatively requires that a vaccine must not be given. A doctor that gives a vaccine in spite of a contraindication could be punished or sued, at least in theory. At the bottom of this article is a table from the CDC website listing contraindications for all vaccines available in the US. Notice that every vaccine has the following contraindication:
Severe allergic reaction (e.g., anaphylaxis) after a previous dose or to a vaccine component
This contraindication is your ticket to getting a medical exemption for any vaccine you do not want. The only thing you have to do is say that you had the vaccine in the past (possibly the distant past, like years ago), and that you experienced symptoms of anaphylaxis afterward.

Before I discuss just how horrible an idea this is (and not just because it advocates blatantly lying to your child’s doctor), let’s see how our “friend” responds to potential objections about how a parent might get caught lying about this critical piece of vaccine history:

Of course, you will have to lie about the symptoms of anaphylaxis. However, if done correctly, there is no way to be caught lying about the symptoms. You will have absolute and total plausible deniability, and in view of this, any doctor will be forced to approve your medical exemption request.

You could be caught lying about receiving the vaccine in the past, but only by someone who has access to your complete medical records, and only for vaccines that are normally documented in medical records. However, some vaccines are given without documentation, such as the flu vaccine, which is given at pharmacies. And sometimes vaccination is not properly recorded. So you can still plausibly claim to have received a vaccine even if it is not documented.

Most people are uncomfortable lying, and that’s (usually) a good thing. Lying can be unethical. But if someone is forcing you to receive an unwanted, harmful vaccine, I believe lying to obtain a medical exemption is completely justified.

Yeah, because doctors asking about vaccines are just like Nazis looking for Anne Frank’s family’s hiding place; so lying is justified. Apparently this is the way this particular antivaxxer thinks. But don’t call him antivaccine! He just thinks that lying about your child’s medical condition to avoid vaccines is ethically justifiable because vaccines are so evil.

Also, many states have statewide databases for vaccination. Any vaccine administered must be entered into the database. In Michigan, for instance, we have the Michigan Care Improvement Registry (MCIR), and all providers, including pharmacies, must report childhood immunizations to the database within 72 hours of administration. Claiming your child was immunized at a pharmacy, contrary to our “friend’s” advice, would not be a way to fool a physician, at least not in this state, as MICR is more than happy to print out a list of vaccines received by a given child upon the request of a physician, be it in this state or any other. I’m not sure which other states have similar databases, but a fair number do.

Of course, none of that stops our antivaccine “friend,” who also has advice on how to fool a doctor who might have access to your child’s complete medical records. How? By claiming that the child suffered a milder, non-life-threatening anaphylactic/allergic reaction:

Claim that the symptoms started about 0.5-2 hours after the vaccine. The more rapid the occurrence of anaphylaxis after exposure, the more likely the reaction is to be severe and potentially life threatening. Do not claim that the symptoms started within minutes. Otherwise, the doctor will wonder why you did not go to the hospital straight from the clinic were you supposedly received the vaccine.
EXAMPLE: “I started feeling strange about 1 hour after the vaccine. Symptoms got worse over the next few hours and persisted into the night. I almost went to the hospital but then it didn’t seem serious enough. I didn’t know what was happening at the time, but now I think I maybe had an anaphylactic reaction to the vaccine.”
And that’s it! Any halfway-competent doctor will immediately conclude that you had an anaphylactic reaction to the vaccine. And there is no way for any doctor, now matter how hostile, to prove you wrong. Since anaphylaxis can be deadly, even the most stubborn and unreasonable vaccine-pushing doctor will be forced to give you the benefit of the doubt and the exemption that is everyone’s right. To do otherwise could create malpractice liability for the doctor and put their license to practice medicine at risk.

No, any halfway competent doctor, upon hearing this history related by the parents, would refer the child to an allergist for a complete workup and allergy testing to identify the component of the vaccine that caused the reaction claimed. That’s the guideline from the American College of Allergy, Asthma and Immunology (ACAAI). Indeed, here’s a more recent set of consensus guidelines (International Consensus, or ICON) from 2016 for how to handle allergic reactions to vaccines, ranging from mild to life-threatening anaphylaxis. It comes from a committee formed by the European Academy of Allergy and Clinical Immunology (EAACI), the American Academy of Allergy, Asthma, and Immunology (AAAAI), and the ACAAI. Of course, because, by our “friend’s” own recommendation, the fake anaphylaxis reaction lied about was not life-threatening, standard allergy skin testing would be safe and indicated after such a history.

Here’s a good summary, liberally quoted from the paper:

Investigation of allergic reactions following the receipt of multiple vaccines simultaneously and/or combined vaccines is increasingly common and can be challenging. If serologic or skin testing are indicated the investigator may choose to prioritize the evaluations based on what they suspect to be the most likely allergens. When proceeding to the administration of additional doses of indicated vaccines, the investigator will need to assess each vaccine separately when possible. Conjugate polysaccharide-protein vaccines may require investigation of the proteins that are conjugated to the polysaccharides as well as other vaccine components as the plain polysaccharides are less likely causes of allergic reactions.

And:

A number of approaches to vaccine skin testing have been suggested but current guidelines recommend that testing be initiated with a prick skin test to the full strength vaccine, unless the patient has a history of severe anaphylaxis in which case it is appropriate to dilute the vaccine 1:10 or even 1:100 to initiate prick skin testing [4, 118] (D). If the prick skin test with full-strength vaccine is negative, an intradermal test with the vaccine diluted 1:100 should then be performed. All tests need to be interpreted carefully with appropriate positive and negative controls, recognizing that falsely positive skin test results may occur. These may be the result of true but clinically irrelevant IgE responses or to irritant effects of the vaccine. A case control study of a child with a history of anaphylaxis to the 23-valent pneumococcal vaccine positive skin tests and in vitro IgE tests to the whole vaccine, included nine controls [121] (C). In one study irritant reactions were common at concentrations of 1:10 or undiluted vaccines, especially with influenza, MMR, and varicella vaccines [122].

At the 1:100 concentration, rates of irritant reactions were far less common with the most frequent being 5 % for DT and DTaP and 15 % for influenza. It is also important to recognize that delayed responses (12–24 h) to vaccine skin tests are common, most likely representing previously established cell-mediated immunity, or immune complex formation in patients with high titers of antibody to vaccine components [123] (D), and should not raise concern in the evaluation of IgE-mediated vaccine allergy [122]. If the suspected vaccine contains specific constituents known to be potentially allergenic, testing should also be conducted for those components. These primarily include egg (for reactions to yellow fever or influenza vaccines), gelatin (see Table 3 for the gelatin content of specific vaccines), latex, and yeast. Skin test reagents for egg and yeast are commercially available. Prick skin test solutions for gelatin can be prepared by dissolving one teaspoon of gelatin powder in 5 mL of normal saline. Skin test extracts for latex are commercially available in many countries but not in the United States. In addition to skin testing, in vitro testing for allergen-specific IgE is available in most commercial laboratories for egg, gelatin, latex, and yeast. For gelatin, it is important that assays for both porcine and bovine products be conducted.

I’m going to steal the figure for the general approach recommended by ICON:

Worksheet for workup after allergy or anaphylaxis to vaccination.

Notice the recommendation: If skin testing and in vitro IgE testing (IgE is a type of antibody) are both negative, then it is safe proceed with vaccination:

If both skin and in vitro testing are negative, especially if the intradermal skin test to the vaccine is negative, the chance that the patient has an IgE-mediated allergy to the vaccine or to any vaccine constituent is very small. The usual dose of the vaccine can therefore be administered with at least a 30 min observation period after vaccination in a facility where anaphylaxis can be recognized and managed with epinephrine and other supportive treatments.

Of course, if a parent lies about an anaphylactic reaction, it is extremely likely that both skin and in vitro IgE tests for the vaccine and the vaccine components most likely to cause severe allergic reactions will be negative. All that lying about anaphylaxis after a vaccine will accomplish is to subject the child to more testing, including blood draws and potentially painful skin tests. If the parent refuses the testing, then a competent physician would not grant a medical exemption, although a competent doc might grant a short term temporary exemption letter (that is, if the state law provides for that) to allow time for the child to undergo a workup for allergies to vaccines and vaccine components.

Only if the skin or in vitro testing is positive, which of course would be extremely unlikely in a child whose parent lied about previous anaphylaxis after vaccination does ICON recommend considering an alternative vaccination schedule:

If skin or in vitro testing to the vaccine or a vaccine component is positive, alternative approaches to vaccination should be considered. However, if the vaccine is considered necessary – that is, the benefit of the vaccine clearly outweighs the potential risk of vaccine administration – it is usually possible to safely administer the vaccine using a graded dose protocol [4]. These decisions should be carefully considered on a case-by-case basis, recognizing that even administration using a graded dose protocol still carries a threoretical risk of anaphylaxis. This should be conducted with informed consent and only in a setting prepared to treat anaphylaxis.

In other words, even in the case of a documented anaphylactic reaction, if the vaccine is deemed important enough it might still be recommended that the child undergo vaccination with precautions to minimize the risk of anaphylaxis. Obviously, such decisions would be made on a case-by-case basis, and most likely a medical exemption would still be justified, but, again, the child of a parent who lied about anaphylaxis after vaccination would be incredibly unlikely to test positive by skin testing or in vitro IgE assessment for an allergy to the vaccine after which anaphylaxis was claimed to have occurred—or to any of its components. ICON even notes that a documented egg allergy is usually not a contraindication to receiving the influenza vaccine!

In the end, all our antivax “friend’s” advice would achieve, at least when used on non-quack physicians, is for the physician to insist on a workup to identify the vaccine and/or component of the vaccine to which the child was claimed to be allergic to the point of anaphylaxis, resulting in unnecessary and potentially painful testing or no exemption. Bad advice like this is the result of not knowing the standard of care or that allergies to vaccines or vaccine components are not diagnosed by history alone without allergy testing and, worse, not even bothering to research what the standard of care is. Of course, not knowing and not bothering to research describe antivaxxers perfectly.