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GUIDELINES FOR MANAGEMENT OF PATIENTS WITH AN ABSENT

OR DYSFUNCTIONAL SPLEEN

People with an absent or dysfunctional spleen are at increased risk of severe infection. The risk
is greatest in the first 2 years following splenectomy, but persists throughout life. The
commonest infection is with Streptococcus pneumoniae, but other organisms also present
significant risks e.g. Haemophilus influenzae type b (Hib) and Neisseria meningitidis.
In January 1994 the Chief Medical Officer wrote to all doctors regarding the consequences of
splenectomy. Further advice was issued in March 2001. The 2006 edition of the book
Immunisation Against Infectious Disease (The Green Book) also gives information on
immunisation of individuals with an absent or dysfunctional spleen.
The following procedures should be followed for all asplenic/hyposplenic patients: 1.

MEDICAL RECORDS
These should be flagged and the patient should carry a card or wear a bracelet/necklet
stating the risk of infection.

2.

VACCINATION
The patients GP should be informed of any vaccines given in hospital.
Ideally the vaccines should be given 4 to 6 weeks before elective splenectomy where
this is not possible they should be given up to 2 weeks before. If it is not practicable to
vaccinate 2 to 6 weeks before splenectomy, immunisation should be delayed until at least
2 weeks after the operation as functional antibody responses may be better at this time.
However, if the patient leaves hospital before this time, the vaccination should be given
before discharge if delaying is likely to result in failure to vaccinate. Vaccination should
be given at least 2 weeks before the initiation of immunosuppressive chemotherapy or
radiotherapy. If this is not possible, immunisation can be delayed for at least 3 months
after completion of treatment in order to maximise the response to the vaccine.
Immunisation of these patients should not be delayed if this is likely to result in a failure to
vaccinate.
A table from The Green Book 2006, p51 detailing the immunisation of individuals with
asplenia or splenic dysfunction is reproduced in Appendix 1.

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Review Date: October 2009

The following vaccines are recommended: a)

Pneumococcal Vaccine
Adults
A single injection of pneumococcal polysaccharide vaccine (PPV) should be given
to adults who have not received a dose of this vaccine in the last 5 years.
Reimmunisation is currently recommended every 5 years.
Children
Children under 2 years should be immunised according to the routine childhood
immunisation schedule (Reproduced in Appendix 2) with pneumococcal conjugate
vaccine (PCV). A dose of PPV [Pneumovax II] is then given after the 2nd birthday,
at least 2 months after the last dose of PCV [Prevenar].
Children aged 2 years to under 5 years who have already been fully vaccinated with
PCV according to the routine childhood schedule should receive an additional dose
of PCV at the time they become hypo/asplenic, followed by a single dose of PPV 2
months later.
Children aged 2 years to under 5 years who have not already received a full course
of PCV should be given 2 doses of PCV 2 months apart followed by a dose of
pneumococcal polysaccharide vaccine (PPV) 2 months after the final PCV dose.
Children aged 5 years and older should follow the schedule for adults. A gap of at
least 2 months should be left after the final dose of PCV before the PPV is given.
Reimmunisation with PPV is recommended every 5 years.

b)

Meningococcal C conjugate vaccine.


Children under 2 years should follow the routine immunisation schedule see
Appendix 2.
Adults, and children of 2 years and over, who have not previously been immunised
with meningococcal C conjugate vaccine (Men C vaccine) according to the UK
schedule should be given 2 doses 2 months apart. These doses are given together
with Hib vaccine, which is also recommended (see below), as the combined
Hib/Men C vaccine Menitorix. Single component Hib vaccine is no longer
available in the UK.
Individuals who have been fully immunised with Men C and Hib vaccine according
the UK schedule previously, but then develop splenic dysfunction, or require a
splenectomy, should be given one dose of Menitorix.
Vaccination can be performed at the same time as pneumococcal vaccination.
See also Hib Catch Up Programme 10/9/07 to 3/3/09 below.

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c)

Haemophilus influenzae type b vaccine (Hib)


Children under 2 years should follow the routine immunisation schedule see
Appendix 2.
Adults and children of 2 years or over, who have not previously been immunised
with Hib vaccine according to the UK schedule should be given 2 doses 2 months
apart. These doses are given as the combined Hib/Men C vaccine Menitorix.
Single component Hib vaccine is no longer available in the UK.
Individuals who have been fully immunised with Men C and Hib vaccine according
the UK schedule previously, but then develop splenic dysfunction, or require a
splenectomy, should be given one dose of Menitorix.
Vaccination can be performed at the same time as pneumococcal vaccination.
Hib Catch Up Programme 10/9/07 to 3/3/09
All children born between 13/3/03 and 3/9/05 are scheduled to be included in this
catch up (See Appendix 2). Take individual immunisation history and any routine
scheduled immunisations into account when prescribing Hib containing vaccines for
children who become hypo/asplenic.

d)

Influenza vaccine
Should be given annually.

3.

ANTIBIOTICS
The first 2 years after splenectomy is the period of highest risk, so antibiotic prophylaxis
should be given for that time, and should also be given to children up to 16 years of age.
Recommended dosages:
Adult
Child 6 - 12
Child <6

phenoxymethyl penicillin

500 mg B.D.
250 mg B.D
125 mg B.D.

Erythromycin should be used in penicillin allergic patients


Adult & Child >8
Child 2 - 8
Child <2

250 - 500 mg daily


250 mg daily
125 mg daily

When long-term prophylaxis is finished, the patient should be given a small supply of a
suitable antibiotic to begin immediately if they have a febrile illness whilst seeking urgent
medical attention.
In patients who are immunosuppressed (e.g. haematology patients, patient on
chemotherapy etc) prophylaxis should be continued for the period of immunosuppression
and may need to be lifelong. This should be decided by the consultant responsible for
their care.
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If the patient starts to feel unwell he/she should be warned to seek medical attention
immediately, even if taking prophylactic antibiotics.
4.

FOREIGN TRAVEL
Malaria poses a threat to people without a functioning spleen. The importance of taking
anti-malarial prophylaxis and other precautions (insect repellents, correct clothing and
screens at night) should be emphasised.
Asplenic/hyposplenic patients travelling to counties in which Group A meningococcal
disease is common e.g. those travelling to sub-Saharan Africa, India and Nepal, will
require meningococcal quadrivalent A, C, W135, Y vaccine. Pilgrims travelling to Saudi
Arabia for Hajj or Umrah will also require the quadrivalent vaccine as outbreaks of
meningococcal W135 infection have occurred there. Boosters for those at ongoing risk
are required every 5 years.
N.B. A period of at least 2 weeks should be left between vaccination with meningococcal
C conjugate vaccine and subsequent vaccination with A, C, W135, Y meningococcal
vaccine.

5.

OTHER MEASURES
Asplenic patients are particularly susceptible to infection following animal bites and insect
bites, and should be alerted to this, so that they attend promptly for appropriate
management.
Capnocytophaga canimorsus may follow animal (particularly dog) bites. The infection
responds to a five-day course of co-amoxiclav.
Babesiosis is a rare tick borne infection which can affect asplenic patients following a tick
bite.
I have no functioning spleen cards can be downloaded from the Department of
Health website (www.dh.gov.uk).
A patient information leaflet can also be
downloaded from the same site.
References
1.

Department of Health. Asplenic patients and immunisation. C.M.Os Update 1994; 1:3.

2.

Department of Health. Meningococcal immunisation for asplenic patients. Current Vaccine & Immunisation Issues. 9
March 2001.

3.

Department of Health Update on Immunisation Issues - CMOs Update August 2002.

4.

Department of Health. The Pneumococcal Immunisation Programme for Older People & Risk Groups. 31 March
2005.

5.

Department of Health. Important Changes to the Childhood Immunisation Programme CMO 12 July 2006.

6.

Department of Health. Immunisation Against Infectious Disease (The Green Book) 2006.

7.

Update of Guidelines for the Prevention and Treatment of Infection in Patients with an Absent or Dysfunctional Spleen.
Clinical Medicine (Journal of the Royal College of Physicians of London, Vol 2, No. 5, Sept/Oct 2002, p 440 - 443).

8.

Department of Health. Haemophilus Influenzae Type b [Hib] Vaccine for Young Children----Catch-up Programme. 23
July 2007.
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APPENDIX 1
Immunisation of individuals with asplenia or splenic dysfunction
Suggested schedule for immunisation in individuals with splenic dysfunction and immunosuppression.
Age at which asplenia or
splenic dysfunction or
immunosuppression
is
acquired

Vaccination schedule
Where possible, vaccination course should ideally be started at least two weeks
before surgery or commencement of immunosuppressive treatment. If not possible,
see advice in pneumo chapter.
Month 0

Month 2

Under two years

Routine immunisation schedule should be followed.*

Over two to under five years


(fully vaccinated including
booster)
Over two to under five years
(unvaccinated or partially
vaccinated)
Five years and older (and
previously vaccinated with
Hib, MenC, PCV vaccines)

Booster dose of Hib/MenC


vaccine
Booster dose of PCV
First dose of Hib/MenC
vaccine
First dose of PCV
Booster dose of Hib/MenC
vaccine
Single dose of PPV
First dose of Hib/MenC
vaccine
Single dose of PPV

Five
years
and
(unvaccinated)

older

Month 4

Single dose of PPV

None

Second dose of Hib/MenC


vaccine
Second dose of PCV

Single dose of PPV

Second dose of Hib/MenC


vaccine

PCV = pneumococcal conjugate vaccine, PPV = pneumococcal polysaccharide vaccine

Taken from the 2006 edition of The Green Book (Immunisation Against Infectious Diseases)
p51
* In addition a dose of PPV is given after the 2nd birthday (at least 2 months after the last dose of
PCV). See page 303 of The Green Book

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Review Date: October 2009

APPENDIX 2
Schedule for the UKs routine childhood immunisations
When to immunise

What vaccine is given

How it is given

Two months old

Diphtheria, tetanus, pertussis (whooping


cough), polio and Hib (DTaP/IPV/Hib)

One injection

Pneumococcal (PCV)

One injection

Diphtheria, tetanus, pertussis (whooping


cough), polio and Hib (DTaP/IPV/Hib)

One injection

Three months old

MenC

One injection

Diphtheria, tetanus, pertussis (whooping


cough), polio and Hib (DTaP/IPV/Hib)

One injection

MenC

One injection

PCV

One injection

Twelve months old

Hib/MenC

One injection

Around 13 months old

Measles, mumps and rubella (MMR)

One injection

Three years four months


*
to five years old

Diphtheria, tetanus, pertussis


(DTaP/IPV or dTaP/IPV)

Four months old

PCV

Thirteen to 18 years old

One injection
and

polio

One injection

Measles, mumps and rubella (MMR)

One injection

Tetanus, diphtheria and polio (Td/IPV)

One injection

Taken from the 2006 edition of The Green Book (Immunisation Against Infectious Diseases)
p80.
*Between 10/9/07 and 3/3/09, the routine childhood schedule includes a Hib catch-up
programme for children born between 13/3/03 and 3/9/05. [These children will not have
received the dose of Hib/Men C which is now scheduled at 12 months old]. Between age 3
years 4 months and 5 years, the above children are scheduled to receive DTaP/IPV/Hib as their
pre school booster instead of DTaP/IPV or dTaP/IPV. Or, if they have already received their
pre school booster without Hib, they are scheduled to receive a dose of Hib/Men C.

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Review Date: October 2009