Table 2.
Immediate and Delayed Adverse Reactions to SARS-CoV-2 Vaccines
| Clinical phenotype | Specific type of vaccine | Risk group | Prevalence | Acute management | Advice for future vaccination |
|---|---|---|---|---|---|
| Immediate reactions | |||||
| Anaphylaxis | mRNA vaccines | Women > men History of previous anaphylaxis is prevalent |
2.5-5.1 events per million11 | Intramuscular epinephrine Serum tryptase |
Refer to allergy and immunology Increasing reports of tolerance of second and subsequent doses in the setting of anaphylaxis to the first dose suggests that a non–IgE-mediated mechanism may be prevalent.61,62 |
| Mild single-system reaction | mRNA vaccines | Women > men | 2.1%20 | Symptomatic management with antihistamines61,62 | Antihistamine premedication before subsequent dosing of mRNA vaccine.61,62 |
| Delayed reactions | |||||
| Mild-to-moderate urticaria | mRNA vaccines | Individuals with underlying urticaria Women > men |
Local reactions 0.8% (dose 1) 0.2% (dose 2)32 | Symptomatic management with ice (for local reactions) topical steroids and antihistamines | No contraindication for second and subsequent doses of vaccine Consider antihistamine premedication |
| Injection site | Women < 65 y | ||||
| Lymphadenopathy | Third dose booster > others | Can be >50% lasting up to 10 wk when sensitive imaging is performed48 | Symptomatic management | No contraindication for second and subsequent doses of vaccine (on side contralateral to tumor or other disease process if patient has known pathology for which they are being staged or followed) | |
| Myocarditis | mRNA vaccines | Men < 30 y | More common on second dose (vs first dose or booster) Estimated risk 12- to 29-y-old males—41 cases/million91 Moderna > Pfizer in Denmark (4.2/100,000 vs 1.4/100,000 vaccinated)51 |
Symptomatic management | Consider subsequent dose with mRNA vaccine on full recovery of all signs and symptoms of myocarditis particularly if patient has comorbidities or is immunosuppressed. Benefit on resolution of all symptoms and signs associated with myopericarditis |
| Guillain-Barré or transverse myelitis | Adenoviral vector vaccines | - | 8/million doses | Symptomatic management | Vaccinate with an alternative vaccine if the conditions is self-limited and resolved |
| Thrombosis with thrombocytopenia (multiple thrombotic episodes venous and arterial) |
Adenoviral vector vaccines (AstraZeneca (ChAdOx1) > Johnson and Johnson (Ad26.COV2.S)) |
Women > men (69% for J&J; median age < 50 y for 48% with J&J vaccine)92 Time course—median 9 d |
3.8/million doses for J&J92 | Avoid heparin Administer thrombin inhibitors IvIg may be of benefit |
Administer mRNA vaccine following occurrence. Since December 16, 2021, CDC recommends mRNA vaccines and the Johnson & Johnson vaccine for initial and booster dosing. |
Abbreviations: IgE, immunoglobulin E; IvIg, intravenous immunoglobulins; J&J, Johnson & Johnson; mRNA, messenger ribonucleic acid; SARS-CoV-2, severe acute respiratory syndrome coronavirus 2.