Splenectomy Vaccine Prophylaxis

• Non-elective splenectomy patients should be vaccinated on or after postoperative day 14.
• Asplenic patients should be revaccinated at the appropriate time interval for each vaccine.
• Elective splenectomy patients should be vaccinated at least 14 days prior to the operation.
• Asplenic or immunocompromised patients (with an intact, but nonfunctional spleen) should be vaccinated as soon as the diagnosis is made

VACCINE	DOSE	ROUTE	REVACCINATION+	Remarks
Polyvalent pneumococcal Pneumovax 23	0.5ml	SC*	·  After 5 years (if 1st dose at >10years) ·  After 3 years (if 1st dose at <10 years)^ ·  Revaccinate all at 65 years	·  Contraindications are Hypersensitivity and Acute severe febrile illness ·  minor infection  such as cold should not result in deferral ·  all injections can be given simultaneously, at different injection site
Haemophilus b conjugate Hiberex	0.5ml	IM* (can SC in thrombocytopenia/ Bleeding disorders	·  none
Quadravalent meningococcal polysaccharide Mencevax ACWY	0.5ml	SC	·  After 2-3 years (if 1st dose at <5 years) ·  After 3-5 years (if 1st dose at >6 years)# ·  Every 3-5 years**

*Administered in the deltoid or lateral thigh region. ^ the Advisory Committee in Immunization + revaccination is not annual # clinical relevance of the waning of antibody titres is unknown and data suggest that revaccination may be appropriate for individuals who remain at high risk of exposure to Neisseria meningitides. Use of conjugate vaccines is recommended when revaccination within two years after administration of the previous Mencevax ACWY dose. The risk of hyporesponsiveness precludes the use of non-conjugated polysaccharide vaccines within this time-period ** if conjugate meningococcal vaccine is used (Menectra)

Meningococcal Revaccination

• Persons at high risk for infection (those with prolonged increased risk for meningococcal disease) have increased susceptibility
• persistent complement component deficiencies; 
• persons with anatomic or functional asplenia; 
• persons with prolonged exposure, including lab workers or travelers to hyperendemic or epidemic areas. 
• Revaccination is also indicated for college freshmen living in dormitories if they received meningococcal polysaccharide vaccine 5 or more years previously
• Revaccination with meningococcal conjugate vaccine (Menactra) is indicated in patients who were previously vaccinated with meningococcal polysaccharide vaccine (Menomune) or meningococcal conjugate vaccine (Menactra) and remain at an increased risk for meningococcal infection. 
• Persons who remain at high risk should then be revaccinated every 5 years. 

ACIP Recommendations for meningococcal polysaccharide Vaccine:

• Children less than 2 years: Not usually recommended. 
• Children 3 to 18 months: Two doses (0.5 mL/dose), 3 months apart, may be considered in  to elicit short-term protection against serogroup A disease. 
• Children 19 to 23 months : A single dose may be considered in (CDC, 2005).
• Children 2 years and older and Adults 55 years or younger: use is not generally recommended; meningococcal conjugate vaccine is preferred (CDC, 2011). 
• If meningococcal conjugate vaccine is unavailable, meningococcal polysaccharide vaccine is an acceptable alternative (CDC, 2005). 
• Persons at prolonged increased risk for meningococcal disease should be revaccinated with meningococcal conjugate vaccine (CDC, 2009).

Recommendation:

1. vaccinations to be carried out at least 14 days prior to surgery
2. no need re-vaccination for HiB, Pneumococcal Vaccine (2nd dose after 3-5 years & 3rd after 65 years)
3. for Meningococcal vaccine, re-vaccination (using Conjugated vaccine) is recommended to be carried out every 5 years by guidelines. However, we only have polysaccharide type, and re-vaccination is only recommended after 3-5 years (2nd dose)
4. no evidence to support 5-yearly use of meningococcal polysaccharide vaccine. It depends on prescriber's judgement and CDC 2005 statement 'acceptable if M.Conjugate is unavailable'.

References:

1. http://www.immune.org.nz/sites/default/files/resources/ProgrammeFundedPrePostSplenectomy20130227V03Final.pdf
2. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4083163/
3. https://spleen.org.au/VSR/Files/RECOMMENDATIONS_Spleen_Registry.pdf
4. https://www.medicines.org.uk/emc/medicine/4204
5. http://www.drugs.com/dosage/meningococcal-polysaccharide-vaccine.html