Here are a few things that we need to remember while immunizing people who have had a splenectomy
Introduction
Approximately 4% of patients undergoing splenectomy develop OPSI and in 1.7% of these patients death will follow. Therefore, the administration of appropriate vaccinations, in conjunction with other therapeutic interventions, is critical to improve survival postsplenectomy.
The Centers for Disease Control and Prevention (CDC) have developed vaccination recommendations for asplenic patients. For those patients undergoing an elective splenectomy, the CDC recommends vaccination with both the pneumococcal and meningococcal vaccines. These vaccines should be administered at least 2 weeks prior to the scheduled surgery. The pneumococcal vaccine should be readmininstered once after ≥ 5 years have elapsed since the initial vaccination. Although the CDC does not recommend the routine administration of theHaemophilus influenza B vaccine prior to splenectomy, many providers will administer this vaccine as well. An annual influenza vaccine is also recommended for asplenic patients. In the event of an emergent splenectomy, it is recommended to administer the needed vaccinations after 2 weeks following the surgery.
The CDC recommends that asplenic travelers contact an international health clinic or the CDC (www.cdc.gov) to obtain information on disease risks within the intended country of travel. Asplenic travelers should be advised of the increased risk for Meningococcal meningitis and recommendation of the A and C vaccine for all asplenic individuals traveling to sub-Saharan Africa, India, and Nepal.
Asplenic patients are susceptible to overwhelming sepsis with encapsulated bacterial pathogens. Although response to vaccines may be less than in people with a functioning spleen, many clinical guidelines recommend immunization against meningococcal, pneumococcal, and Haemophilus influenzae disease in these patients, regardless of travel plans.
- Limited data show that vaccine response in people who have had a splenectomy was more impaired if splenectomy was performed because of hematologic malignancy rather than for splenic trauma.
- The meningococcal A/C/Y/W-135 conjugate vaccine is indicated for both pediatric and adult populations at risk.
- The polysaccharide-protein conjugate vaccine against disease due to H. influenzae type b (Hib conjugate vaccine) appears to elicit an increased immune response and duration of protection in vaccine recipients, and many experienced clinicians recommend a single dose for splenectomized patients.
- Streptococcus pneumoniae vaccine is recommended for asplenic patients (Table 8-01).
ACIP Recommendations for PCV13 and PPSV23 Use
Adults with specified immunocompromising conditions who are eligible for pneumococcal vaccine should be vaccinated with PCV13 during their next pneumococcal vaccination opportunity.
Pneumococcal vaccine-naïve persons. ACIP recommends that adults aged ≥19 years with immunocompromising conditions, functional or anatomic asplenia, CSF leaks, or cochlear implants, and who have not previously received PCV13 or PPSV23, should receive a dose of PCV13 first, followed by a dose of PPSV23 at least 8 weeks later (Table). Subsequent doses of PPSV23 should follow current PPSV23 recommendations for adults at high risk. Specifically, a second PPSV23 dose is recommended 5 years after the first PPSV23 dose for persons aged 19–64 years with functional or anatomic asplenia and for persons with immunocompromising conditions. Additionally, those who received PPSV23 before age 65 years for any indication should receive another dose of the vaccine at age 65 years, or later if at least 5 years have elapsed since their previous PPSV23 dose.
Previous vaccination with PPSV23. Adults aged ≥19 years with immunocompromising conditions, functional or anatomic asplenia, CSF leaks, or cochlear implants, who previously have received ≥1 doses of PPSV23 should be given a PCV13 dose ≥1 year after the last PPSV23 dose was received. For those who require additional doses of PPSV23, the first such dose should be given no sooner than 8 weeks after PCV13 and at least 5 years after the most recent dose of PPSV23.
Here are the references for the same
http://wwwnc.cdc.gov/travel/yellowbook/2014/chapter-8-advising-travelers-with-specific-needs/immunocompromised-travelers
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6140a4.htm
The references below are NOT updated and do not reflect current recommended practices
http://www.uic.edu/pharmacy/centers/drug_information_center/faq/asplenic.php
http://www.surgicalcriticalcare.net/Guidelines/splenectomy_vaccines.pdf
http://www.patient.co.uk/doctor/splenectomy-hyposplenism-and-asplenia
http://clinicalpharmacy.ucsf.edu/idmp/ucsf_specific/postsplenectomy.htm
Table 8-01. Immunization of immunocompromised adults
| HIV INFEC- TION, CD4 CELLS ≥200/ mm3 | SEVERE IMMUNO- SUPPRES- SION (HIV/ AIDS) CD4 CELLS <200 br="" style="margin: 0px; padding: 0px;">mm3 | SEVERE IMMUNO- SUPPRES- SION (NOT HIV- RELATED) | ASPLENIA | RENAL FAILURE | CHRONIC LIVER DISEASE, DIABETES | |
|---|---|---|---|---|---|---|
| Live Vaccines | ||||||
| Bacillus Calmette Guérin (BCG) | X | X | X | U | U | U |
| Influenza, live attenuated (LAIV) | X | X | X | U | X | X |
| Measles-mumps-rubella (MMR) | R1 | X1 | X1 | U | U | U |
| Typhoid, Ty21a | X | X | X | U | U | U |
| Varicella (adults)2 | U | X | X | U | U | U |
| Yellow Fever3 | P3 | X3 | X | U | W | W |
| Zoster | C4 | X4 | X | U | U | U |
| Inactivated Vaccines | ||||||
| Haemoph- ilus influenzaetype b (Hib) | C5 | C5 | R | R | U | U |
| Hepatitis A6 | U | U | U | U | U | U |
| Hepatitis B6 | U7 | U7 | U7 | U7 | R8 | U7 |
| Influenza (inacti- vated) | R | R | R | R | R | R |
| Japanese encepha- litis9 | U | U | U | U | U | U |
| Meningo- coccal conjugate | C10 | C10 | U | R10 | U | U |
| PCV13 followed by PPSV2311 | R | R | R | R | R | C |
| Polio (IPV) | U | U | U | U | U | U |
| Rabies | U | U | U | U | U | U |
| Td or Tdap | R | R | R | R | R | R |
| Typhoid, Vi | U | U | U | U | U | U |
Abbreviations: X, Contraindicated (per the Advisory Committee on Immunization Practices [ACIP]); U, Use as indicated for normal hosts; R, Recommended for all in this patient category; P, Precaution (per ACIP); W, Warning—medical conditions for which no data regarding YF vaccine exist but for which varying degrees of immune deficit might be present and could increase the risk of serious adverse events following vaccination; providers should carefully weigh vaccine risks and benefits before deciding to vaccinate such patients; C, Consider; PCV13, 13-valent pneumococcal conjugate vaccine; PPSV23, 23-valent pneumococcal polysaccharide vaccine.
1MMR vaccination should be considered for all symptomatic HIV-infected patients with CD4 counts ≥200/mm3 without evidence of measles immunity. Immune globulin may be administered for short-term protection of those facing high risk of measles and for whom MMR vaccine is contraindicated.
2Varicella vaccine should not be administered to people who have cellular immunodeficiencies, but people with impaired humoral immunity (including congenital or acquired hypoglobulinemia or dysglobulinemia) may be vaccinated. Immunocompromised hosts should receive 2 doses of vaccine spaced at 3-month intervals.
3See details in Chapter 3, Yellow Fever. YF vaccination is a precaution for asymptomatic HIV-infected people with CD4 cell counts of 200–499/mm3. YF vaccination is not a precaution for people with asymptomatic HIV infection and CD4 cell counts ≥500. YF vaccine is also considered contraindicated by ACIP for symptomatic HIV patients without AIDS and with CD4 counts ≥200/mm3.
4Also contraindicated by ACIP for symptomatic HIV patients without AIDS and with CD4 counts ≥200/mm3.
5Decision should be based on consideration of the individual patient’s risk of Hib disease and the effectiveness of the vaccine for that person. In some settings, the incidence of Hib disease may be higher among HIV-infected adults than among HIV-uninfected adults, and the disease can be severe in these patients.
6Routinely indicated for all men who have sex with men, people with multiple sexual partners, hemophiliacs, patients with chronic hepatitis, and injection drug users.
7Test for antibodies to hepatitis B virus surface antigen serum titer after vaccination, and revaccinate if initial antibody response is absent or suboptimal (<10 500="" a="" cd4="" cell="" counts="" course="" hiv-infected="" if="" may="" miu="" ml="" mm="" nonresponders="" react="" rise="" span="" style="bottom: 0.33em; margin: 0px; padding: 0px 3px 0px 0px; position: relative; vertical-align: baseline;" subsequent="" to="" vaccine="">3
1MMR vaccination should be considered for all symptomatic HIV-infected patients with CD4 counts ≥200/mm3 without evidence of measles immunity. Immune globulin may be administered for short-term protection of those facing high risk of measles and for whom MMR vaccine is contraindicated.
2Varicella vaccine should not be administered to people who have cellular immunodeficiencies, but people with impaired humoral immunity (including congenital or acquired hypoglobulinemia or dysglobulinemia) may be vaccinated. Immunocompromised hosts should receive 2 doses of vaccine spaced at 3-month intervals.
3See details in Chapter 3, Yellow Fever. YF vaccination is a precaution for asymptomatic HIV-infected people with CD4 cell counts of 200–499/mm3. YF vaccination is not a precaution for people with asymptomatic HIV infection and CD4 cell counts ≥500. YF vaccine is also considered contraindicated by ACIP for symptomatic HIV patients without AIDS and with CD4 counts ≥200/mm3.
4Also contraindicated by ACIP for symptomatic HIV patients without AIDS and with CD4 counts ≥200/mm3.
5Decision should be based on consideration of the individual patient’s risk of Hib disease and the effectiveness of the vaccine for that person. In some settings, the incidence of Hib disease may be higher among HIV-infected adults than among HIV-uninfected adults, and the disease can be severe in these patients.
6Routinely indicated for all men who have sex with men, people with multiple sexual partners, hemophiliacs, patients with chronic hepatitis, and injection drug users.
7Test for antibodies to hepatitis B virus surface antigen serum titer after vaccination, and revaccinate if initial antibody response is absent or suboptimal (<10 500="" a="" cd4="" cell="" counts="" course="" hiv-infected="" if="" may="" miu="" ml="" mm="" nonresponders="" react="" rise="" span="" style="bottom: 0.33em; margin: 0px; padding: 0px 3px 0px 0px; position: relative; vertical-align: baseline;" subsequent="" to="" vaccine="">3
8Use special double-dose vaccine formulation. Test for antibodies to hepatitis B virus surface antigen after vaccination and revaccinate if initial antibody response is absent or suboptimal (<10 br="" miu="" ml="" nbsp="" style="margin: 0px; padding: 0px;">9As with most inactivated vaccines, no safety or efficacy data exist regarding the use of Ixiaro in immunocompromised people. Immunocompromised people may have a diminished immune response to Ixiaro.
10Two doses ≥2 months apart for asplenic and HIV-infected patients.
11Previously unimmunized asplenic, HIV-infected, or immunocompromised adults aged ≥19 years should receive 1 dose of 13-valent pneumococcal conjugate vaccine (PCV13) followed by 1 dose of pneumococcal polysaccharide vaccine (PPSV23) ≥8 weeks later. People with these conditions previously immunized with PPSV23 should follow catch-up guidelines per ACIP.
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