Splenectomy : Immunisation in Adults

·       In order to optimize the immune response to vaccination, we vaccinate patients at least 2 weeks, and ideally 10 to 12 weeks, prior to splenectomy when possible.

·       In addition, routine vaccinations for which the individual would be due should also be provided, as these are more likely to be effective in an individual with an intact spleen.

·       When vaccines cannot be given at least two weeks prior to splenectomy, we vaccinate approximately two weeks after the procedure. Appropriate vaccinations that were not administered before splenectomy should be given. (However, please check if they can be given together)

·       Recommended antibiotic prophylaxis post splenectomy: PO Amoxicillin 250-500 mg orally OD to BD (duration may be 3 years to lifelong, depending on individual circumstances), kindly use alternative such as macrolide (e.g. PO Clarithromycin 250mg BD or PO Erythromycin) in the case of penicillin allergy.

·       If patient developed sudden unexplained fever or any signs of infection, kindly see a Dr immediately.

Vaccine	Timing of First Dose	Booster / Revaccination	Remarks
Penumococcal (Pneumovax-23)	Elective: 2-12 weeks before elective surgery   OR   Non-elective: 14 days post-splenectomy or at the time of hospital discharge, whichever comes first   Vaccination may be considered upon discharge if patient is expected not to return for follow-up	Every 5 years	USA CDC 2021: At age 65 years or older, give 1 dose PPSV23 at least 5 years after most recent PPSV23 ·  P/S: only 1 dose PPSV23 recommended at age 65 years or older ·  P/S: Some references (like Australian) only administer a maximum of 3 doses of Pneumovax-23 during adulthood.   ·  It is recommended to give 1 dose of PCV13 followed by 1 dose of PPSV23 ≥8 weeks later. However, PCV13 is under paediatric budget in HKGU.
Haemophilus influenza type b (Hib)		Not needed
Meningococcal vaccines polysaccharide (Menactra)		2nd dose given at least 8 weeks after 1st dose, then every 5 years if risk remains	Menactra must be given four weeks after PCV13 because Menactra may interfere with the protection conferred by pneumococcal conjugate vaccines.   USA CDC 2021: A quadrivalent meningococcal conjugate vaccine that protects against meningococcal serotypes A, C, W, and Y (e.g. MenACWY; Menactra) and a univalent serogroup B vaccine (MenB-4C [Bexsero] or MenB-FHbp [Trumenba]). Both vaccines are given as a primary series. However only Menactra available in HKGU
Seasonal influenza vaccination		Once yearly	Although live attenuated vaccines can be safely given to patients with impaired splenic function, the inactivated influenza vaccine is preferred over the live formulation because it is equally effective

 

References:

1.     Uptodate: Elective (diagnostic or therapeutic) splenectomy

2.     Uptodate: Vaccinations for adults (age >19 years) with impaired splenic function and adults undergoing splenectomy in the United States*

3.     Uptodate: Prevention of infection in patients with impaired splenic function

4.     Guidelines for Adult Immunisation (Malaysia), 2nd Edition, 2014

5.     USA CDC 2021. Recommended Adult Immunization Schedulefor ages 19 years or older (Last updated on 11/2/2021).

6.     Relihan K. Post-splenectomy Vaccine Prophylaxis – Evidence Based Medicine Guideline (Last revised on 8/4/2021). Available online at: http://www.surgicalcriticalcare.net/Guidelines/Post%20Splenectomy%20vaccines%202021.pdf

7.     Department for Health and Ageing, Government of South Australia. Splenectomy vaccination and Antimicrobial Prophylaxis (Adult asplenic and hyposplenic patients) Clinical Guideline (Approved on 25/07/2019).

8.     https://spleen.org.au/wp-content/uploads/2020/03/RECOMMENDATIONS_Spleen_Registry.pdf

9.     Cork Emergency Medicine. Management Patients Post-Splenectomy & Hyposplenic Patients (Last reviewed 26/05/2021). Available online at: https://emed.ie/Infections/Prophylaxis/Hyposplenic.php

10.   University of Michigan. UMHHC Immunization Committee Vaccination Record for People with a Splenectomy or Splenic Embolization (Last revised on 07/09/2019).

11.   National Antimicrobial Guideline 2019 (Malaysia).

 

All info accessed on 27 May 2021 [J. Ho]

Comparison of Diphtheria-Toxoid-Containing Vaccine

 

* Blue = For age < 7  

* Orange = For age ≥ 7

 

Comparing 1 dose = 0.5 ml each	Diphtheria Toxoid	Tetanus Toxoid	Alumiunum	Thiomersal	Pregnancy	Remarks
Diphtheria and Tetanus Vaccine Adsorbed (Pediatric)  Available in PKK Keningau	≤ 25 Lf (≥ 30 IU)	≥ 5 Lf (≥ 40 IU)	Al+++ ≤ 1.25 mg	0.005%	Not mentioned in product leaflet	·        Recommended for below 7 years old ·        For 7 years old and older, a special DT vaccine, containing a reduced amount of diphtheria toxoid is recommended.
Hexaxim DTaP- IPV-HB-Hib Available in PKK Keningau	≥ 20 IU	≥ 40 IU	Al(OH)3      0.6 mg Al3+	Not stated	Not applicable. Not intended for administration in women of child-bearing age	For primary and booster vaccination of hose 6 weeks to 24 months of age.
Adsorbed DT Vaccine (Malaysia)	20 Lf	7.5 Lf	Alumimium phosphate  1.5 mg	0.05 mg	Not applicable.	For below 7 years old
TDVAX™ Td (for age 7 and above in USA)	2 Lf	2 Lf	Less than 0.53 mg aluminium adjuvant	Trace amount, with ≤ 0.3 mcg mercury / dose	Animal reproduction studies have not been conducted with MassBiologics’ TDVAX. It is also not known whether MassBiologics’ TDVAX can cause fetal harm when administered to a pregnant woman or can affect reproduction capacity. MassBiologics’ TDVAX should be given to a pregnant woman only if clearly needed.	Td (for age 7 and above in USA)
Boostrix  Tdap  Agihan Khas JKNS	≥ 2 IU (2.5 Lf)	≥ 20 IU (5 Lf)	Al(OH)3      0.3 mg Al3+ AlPO4           0.2 mg Al3+	Not stated	·    The use of Boostrix may be considered during the third trimester of pregnancy. ·    Safety data from a prospective observational study where Boostrix was administered to pregnant women during the third trimester (793 pregnancy outcomes) as well as data from post-marketing surveillance where pregnant women were exposed to Boostrix or to Boostrix Polio (dTpa-IPV vaccine) have shown no vaccine related adverse effect on pregnancy or on the health of the foetus/newborn child. ·    Human data from prospective clinical studies on the use of Boostrix during the first and second trimester of pregnancy are not available. ·    Limited data indicate that maternal antibodies may reduce the magnitude of the immune response to some vaccines in infants born from mothers vaccinated with Boostrix during pregnancy. The clinical relevance of this observation is unknown. ·    Animal studies do not indicate direct or indirect harmful effects with respect to pregnancy, embryonal/foetal development, parturition or post-natal development. ·   Boostrix should only be used during pregnancy when the possible advantages outweigh the possible risks for the foetus.	For booster vaccination against diphtheria, tetanus and pertussis for age 4 years and above.

 

https://www.who.int/vaccine_safety/initiative/tools/DTP_vaccine_rates_information_sheet.pdf   INFORMATION SHEET OBSERVED RATE OF VACCINE REACTIONS DIPHTHERIA, PERTUSSIS, TETANUS VACCINES (WHO, 2014)	Diphtheria toxoid - Diphtheria toxoid is prepared by formalin inactivation of diphtheria toxin. Usually it is available as a preparation adsorbed with aluminium hydroxide or phosphate and combined with other toxoids or vaccine antigens. The potency of diphtheria vaccine used for the immunization of children should not be less than 30 IU per single human dose, while for adults; the potency is about a third of the dose for children. Monovalent single antigen diphtheria toxoid is currently commercially unavailable.   Tetanus toxoid - Tetanus toxoid is a preparation of formalin inactivated toxin. The toxoid is available adsorbed with aluminium phosphate or hydroxide, alone or in combination with other toxoids or vaccines. The potency of tetanus toxoid, expressed in International Units, varies widely according to the preparation and the manufacturer, but WHO stipulates the potency of tetanus vaccine used for the immunization of children should not be less than 40 IU per single human dose. The minimum potency specification for tetanus vaccine intended for booster immunization of older children and adults may be lower and should be approved by the National Regulatory Authority (NRA). Single antigen adsorbed tetanus toxoid is available with a toxoid content of 2 to 10 Lf/dose   Diphtheria and Tetanus (DT and Td) toxoid combination: DT vaccine used for primary immunisation and boosting in children contains 6.7-25Lf of diphtheria toxoid and 5 – 7.5 Lf of tetanus toxoid per dose. An adult combination, Td, is used for boosting and primary immunisation in adolescents and adults and contains a lower dose of diphtheria (less than 2 Lf/dose) but a similar dose of tetanus toxoid
UptoDate: Tetanus-diphtheria toxoid vaccination in adults	·         In the United States, a diphtheria-tetanus toxoid (DT and Td) or diphtheria toxoid-tetanus toxoid-acellular pertussis vaccine (DTaP and Tdap; Adacel or Boostrix) vaccine 0.5 mL intramuscularly (IM) is recommended every 10 years for all adults with complete prior immunization against tetanus and diphtheria [2,4,5]. ·         At least one of those doses should be with Tdap in adults aged 19 years and older who had not received Tdap previously. ·         When indicated, Tdap should be administered regardless of the interval since the last dose of Td. ·         Subsequently, booster doses with either Td or Tdap can be resumed 10 years later.
USA CDC 2021	·         If a tetanus-toxoid-containing vaccine is indicated for a pregnant woman, use Tdap. ·         Pregnancy: 1 dose Tdap during each pregnancy, preferably in early part of gestational weeks 27 to 36.
UptoDate: Immunizations during Pregnancy	Vaccination with the tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) is routinely recommended during pregnancy [3]. Pregnant women who had not previously been fully vaccinated against tetanus and diphtheria should also receive a tetanus and diphtheria toxoid (Td) series.
UptoDate: Diphtheria and tetanus toxoid vaccines (DT [age <7 years] and Td [age ≥7 years]): Drug information	Td vaccines (eg, TDVax, Tenivac) are for use in patients ≥7 years of age; DT vaccines (generics) are for use in pediatric patients 6 weeks to <7 years of age. Td vaccines contain less diphtheria toxoid than DT vaccines; the vaccines are not interchangeable.   b Tetanus toxoid in this chart refers to a tetanus toxoid-containing vaccine. ·         For children <7 years of age, DTaP (DT, if pertussis vaccine contraindicated) is recommended. ·         For children 7 to 10 years of age who are not fully immunized against pertussis, diphtheria, or tetanus, Tdap should be used (followed by completion of catch-up series). ·         Tdap is preferred in patients ≥11 years of age if the patient has not previously been vaccinated with Tdap, if Tdap history is unknown, or if the patient is pregnant. ·         In patients who have previously been vaccinated with Tdap, either Td or Tdap may be used.   In general, maternal use of inactivated vaccines is not associated with increased risks to the fetus (ACIP [Kroger 2021]). Diphtheria toxoid and tetanus toxoid vaccines may be used during pregnancy (CDC/ACIP [Liang 2018]).   The Advisory Committee on Immunization Practices (ACIP) recommends a single Tdap vaccination during each pregnancy; ideally early in the period between 27 and 36 weeks' gestation to maximize passive antibody transfer to the fetus. Pregnant females who are not immunized or are only partially immunized should complete the primary series with Td or Tdap. Tetanus immune globulin and a tetanus toxoid containing vaccine are recommended by the ACIP as part of the standard wound management to prevent tetanus in pregnant females; the use of a tetanus-toxoid containing vaccine during pregnancy (with preference given to Tdap) is recommended for wound management if ≥5 years have passed since the last Td vaccination (CDC/ACIP [Havers 2020]); CDC/ACIP [Liang 2018]).
CDC: Tdap Vaccine Safety for Mother and Infant	Pregnant women have been getting both tetanus and diphtheria toxoids (Td) and tetanus toxoid (TT) vaccines worldwide since the 1960s to prevent neonatal tetanus. Td and TT vaccines administered during pregnancy have not been shown to harm either the mother or baby / fetus. https://www.cdc.gov/pertussis/pregnant/hcp/vaccine-safety.html#:~:text=The%20tetanus%20toxoid%2C%20reduced%20diphtheria,administer%20any%20time%20during%20pregnancy.
American College of Obstetricians and Gynaegologists: Update on Immunization and Pregnancy: Tetanus, Diphtheria, and Pertussis Vaccination	In 2013, the Advisory Committee on Immunization Practices published its updated recommendation that a dose of tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) should be administered during each pregnancy, irrespective of the prior history of receiving Tdap. The recommended timing for maternal Tdap vaccination is between 27 weeks and 36 weeks of gestation. To maximize the maternal antibody response and passive antibody transfer and levels in the newborn, vaccination as early as possible in the 27–36-weeks-of-gestation window is recommended. However, the Tdap vaccine may be safely given at any time during pregnancy if needed for wound management, pertussis outbreaks, or other extenuating circumstances. There is no evidence of adverse fetal effects from vaccinating pregnant women with an inactivated virus or bacterial vaccine or toxoid, and a growing body of robust data demonstrate safety of such use.   A pregnant woman should not be revaccinated with Tdap in the same pregnancy if she received the vaccine in the first or second trimester.   https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2017/09/update-on-immunization-and-pregnancy-tetanus-diphtheria-and-pertussis-vaccination

 

Conclusion:

·         Only vaccines with reduced diphtheria component are recommended in adults (age 7 and above) and pregnancy.

·         Generally when comparing diphtheria/tetanus-covering vaccine, the tetanus toxoid component is similar, while the diphtheria toxoid content is about 3-15 times higher in < 7 years old formulation.

·         No information or recommendation can be found regarding use of paediatrics DT vaccine in population 7 years old and above.

·         No information can be found on the potential impact if population 7 years old and above given extra diphtheria toxoid.

 

Useful References / Further Reading:

1.        https://www.cdc.gov/vaccines/vpd/dtap-tdap-td/hcp/about-vaccine.html#:~:text=Diphtheria%20and%20Tetanus%20(DT%20and%20Td)%20Only%20Vaccines&text=Each%200.5%2Dmilliliter%20(mL),%2C%20is%20less%20than%200.02%25.

 

All information accessed on 19 May 2021 [J. Ho]