Potential Mechanisms of Anaphylaxis to COVID-19 mRNA Vaccines

Risma, Kimberly A.; Edwards, Kathryn M.; Hummell, Donna S.; Little, Frederic F.; Norton, Allison E.; Stallings, Amy; Wood, Robert A.; Milner, Joshua

Anaphylaxis to vaccines is historically a rare event. The Coronavirus Disease 2019 (COVID-19) pandemic drove the need for rapid vaccine production applying a novel antigen delivery system: mRNA vaccines packaged in lipid nanoparticles (LNP). Unexpectedly, public vaccine administration led to a small number of severe allergic reactions with resultant substantial public concern, especially within atopic individuals. We reviewed the constituents of the mRNA LNP vaccine and considered several contributors to these reactions: 1) contact system activation by nucleic acid, 2) complement recognition of the vaccine activating allergic effector cells, 3) pre-existing antibody recognition of polyethylene glycol (PEG), a LNP surface hydrophilic polymer, and 4) direct mast cell activation, coupled with potential genetic or environmental predispositions to hypersensitivity. Unfortunately, measurement of anti-PEG antibodies in vitro is not clinically available, and the predictive value of skin testing to PEG components as a COVID-19 mRNA vaccine-specific anaphylaxis marker is unknown. Even less is known regarding the applicability of vaccine use for testing (in vitro/vivo) to ascertain pathogenesis or predict reactivity risk. Expedient and thorough research-based evaluation of patients who have suffered anaphylactic vaccine reactions and prospective clinical trials in putative at-risk individuals are needed to address these concerns during a public health crisis.