Asplenia and hyposplenia vaccination and prophylaxis

Disclaimer These guidelines have been produced to guide clinical decision making for the medical, nursing and allied health staff of Perth Children’s Hospital. They are not strict protocols, and they do not replace the judgement of a senior clinician. Clinical common sense should be applied at all times. These clinical guidelines should never be relied on as a substitute for proper assessment with respect to the particular circumstances of each case and the needs of each patient. Clinicians should also consider the local skill level available and their local area policies before following any guideline.  Read the full PCH Emergency Department disclaimer.

Aim

To provide guidance to PCH clinical staff on the vaccination schedule and prophylactic antibiotic therapy for children who have no spleen (asplenia) or a non-functioning spleen (hyposplenia).

Background^1,2 

1. Streptococcus pneumoniae (Pneumococcus)

Due to higher disease burden and the potential for poorer antibody responses, children diagnosed with asplenia/hyposplenia at age ≤ 12 months are recommended to receive an additional 13vPCV dose (4th dose) and 3 lifetime doses of 23vPPV. Catch-up schedules for children diagnosed at an older age are outlined in Table 1.

Table 1: Pneumococcal vaccines (derived from AIH 10th edition)³

Current age	Number of 13vPCV doses previously received	Age at presentation	Age at 1st PCV dose	Number of 13vPCV doses required #+	Number of 23vPPC doses required
< 5 years	None	< 12 months	N/A	4	3 lifetime doses **
		12 - 59 months	N/A	2
	1	< 12 months	N/A	3
		12 - 59 months	< 12 months	2
			> 12 months	1
	2	< 12 months	N/A	2
		12 - 59 months	< 12 months	2 (if 2nd dose received at age > 12 months, 1 further 13vPCV dose is required)
			> 12 months	-
	3	< 12 months	N/A	1
		12-59 months	< 12 months	1 (if 2nd and 3rd doses received at age > 12 months, no furhter 13vPCV doses are required)
	4	N/A	N/A	-
5 to 17 years	0	N/A	N/A	1	3 lifetime doses **
	>1 (excluding Prevenar7 and Prevenar10)	N/A	N/A	-

# 13vPCV (Prevenar13)/ 23vPPV (Pneumovax23); route IM, dose 0.5ml. The minimum interval between 13vPCV dose(s) is 1 month if aged <12 months, and 2 months if aged ≥12 months. The minimum interval between 13vPCV (recommended to be given first) and 23vPPV is 2 months. If 23vPPV is given first, a minimum interval of 12 months is recommended before 13vPCV can be given.

** The first 23vPPV dose should be given at age 4-5 years and at a minimum of 2 months after the last 13vPCV dose. The second dose of 23vPPV is recommended 5 years after the first and at a minimum of 2 months after 13vPCV. The third 23vPPV dose should be approximately 10 years after the second, or at age 18–20 years, whichever is later.

+ Menactra (MenACWY) should not be co-administered with 13vPCV as Menactra may interfere with the immune response against some pneumococcal serotypes. If co-administered, the 13vPCV dose should be repeated a minimum of 8 weeks later. Menveo and Nimenrix can be co-administered with 13vPCV.

2. Neisseria meningitidis (Meningococcus)

All patients require additional vaccines against N. meningitidis, which are hospital funded, including vaccinations against meningococcal ACWY (4vMenC) and meningococcal B (MenBV).

Table 2: Meningococcal ACWY vaccines (4vMenC) (derived from AIH 10th edition)³

Age at commencement	Recommended brand(s)#	Number of primary 4vMenC doses#	Recommended interval between primary doses	Timing of booster 4vMenC doses
6 weeks to 5 months	Menveo OR  Nimenrix	4	8 weeks; 4th dose at 12 months of age or 8 weeks after 3rd dose, whichever is later	3 years after completing primary schedule, then every 5 years thereafter
6 - 8 months	Menveo OR  Nimenrix	3	8 weeks; 3rd dose at 12 months of age or 8 weeks after 2nd dose, whichever is later	3 years after completing primary schedule, then every 5 years thereafter
9 -11 months	Menveo OR   Nimenrix OR	3	8 weeks; 3rd dose at 12 months of age or 8 weeks after 2nd dose, whichever is later	3 years after completing primary schedule, then every 5 years thereafter
> 12 months	Menveo OR   Nimenrix OR	2	8 weeks	If primary course completed at ≤ 6 years of age - 3 years after completing primary schedule, then every 5 years thereafter. If primary course completed at ≥ 7 years of age – every 5 years after completing primary schedule.

# Menveo/Niminrix; route IM, dose 0.5ml. 4vMenC and MenBV can be given at the same time

Menveo or Niminrix are the preferred brands over Menactra. Menactra should not be co-administered with 13vPCV as Menactra may interfere with the immune response against some pneumococcal serotypes. If co-administered, the 13vPCV dose should be repeated a minimum of 8 weeks later. Menveo and Nimenrix can be co-administered with 13vPCV.

Table 3: Meningococcal B vaccine (MenBV) (derived from AIH 10th edition)³

Age at commencement	Recommended brand	Number of primary MenBV doses+	Interval between doses
6 weeks to 5 months	Bexsero	4	8 weeks; 4th dose at 12 months of age or 8 weeks after 3rd dose, whichever is later
6 - 11 months	Bexsero	3	8 weeks; 3rd dose at 12 months of age or 8 weeks after 2nd dose, whichever is later
12 months to 9 years	Bexsero	2	8 weeks
> 10 years	Bexsero OR	2	8 weeks
	Trumenba	3	At 0, 1 and 6 months

⁺All MenBV vaccines (Bexsero & Trumenba) route IM, dose 0.5ml. 4vMenC and MenBV can be given at the same time. Prophylactic use of paracetamol is recommended when MenBV is administered to children < 2 years of age. There is an increased risk of fever when MenBV is co-administered with other routine vaccines, however this is not a contraindication.

3. Influenza

Table 4: Influenza vaccine (derived from AIH 10th edition¹)³

Age £	Influenza vaccine brand	Route	Dose	Number of doses required if receiving the Influenza vaccine for the first time	Number of doses required if previously received one or more doses of influenza vaccine
6 months to <3 years	FluQuadri Junior	IM	0.25mL	2 doses, minimum 4 weeks apart	1 dose
3 years to < 9 months	Fluarix Tetra or FluQuadri	IM	0.5mL	2 doses, minimum 4 weeks apart	1 dose
9 years and over	Fluarix Tetra or FluQuadri	IM	0.5mL	1 dose*	1 dose

^£ All children with asplenia require annual influenza vaccine at the start of each influenza season, given their increased risk of severe infection.

* If the child/adolescent with asplenia has had a solid organ or haematopoietic stem cell transplant, 2 doses of influenza vaccine are recommended during their first year of influenza vaccination after transplantation.

4. Haemophilus influenzae B vaccine (derived from the AIH 10th edition)³

Age at diagnosis	Vaccine history			Number of further primary doses required	Number of booster doses required at age > 18 months of age, or 2 months after the last dose, whichever is later
	Number of previous Hib doses	Current age (months)	Age at time of 1st Hib vaccine (months)
6 weeks to < 5 years	No previous Hib doses	< 7 months	N/A	3	1
		7 - 11 months	N/A	2	1
		12 - 17 months	N/A	1	1
		18 - 59 months	N/A	1	-
	1 previous Hib dose	< 12 months	< 7 months	2	1
			7-11 months	1	1
		12-17 months	< 12 months	1	1
			> 12 months	-	1
		18-59 months	< 18 months	-	1
			> 18 months	-	-
	2 previous Hib doses	< 12 months	< 7 months	1	1
		< 17 months	7-11 months	-	1
		12 - 17 months	> 12 months	-	-
		18 - 59 months	< 12 months	-	1
			> 12 months	-	-
	3 Hib doses received previously	All 3 doses at < 12 months		-	1
		> 1 dose at 12-17 months		-	-
> 5 years	Primary course complete			-	-
	Never received a dose of Hib-containing vaccine or primary course incomplete			-	1

^# For all Hib containing vaccines; route IM, dose 0.5ml. The minimum interval between primary doses for Hib is 4 weeks. Hib age appropriate combination vaccines are acceptable, e.g DTPa- HepB-IPV-Hib (Infanrix-hexa) on schedule at 6 weeks, 4 and 6 months. Monovalent Hib vaccines (Hiberix & Act-HIB) are registered for use in infants and children from age 2 months – 5 years.

5. Antibiotic prophylaxis ^4,5

Prophylactic antibiotics should be administered until patients are at least 5 years of age and for at least 2 years following splenectomy. Lifelong prophylaxis may be warranted and must be addressed on a case by case basis.

Refer to the Asplenia/Hyposplenia Management Plan. Further advice can be sought from an Infectious Diseases Specialist.

Age at diagnosis	Prophylactic antibiotic
< 1 year	Amoxicillin 20mg/kg/dose (up to 250mg) once daily OR Phenoxymethylpenicillin (Penicillin V) 62.5mg twice daily
1 - 5 years	Amoxicillin 20mg/kg/dose (up to 250mg) once daily OR Phenoxymethylpenicillin (Penicillin V) 125mg twice daily
> 5 years	Amoxicillin 20mg/kg/dose (up to 250mg) once daily OR Phenoxymethylpenicillin (Penicillin V) 250mg twice daily
If confirmed penicillin allergy	Roxithromycin 4mg/kg/dose (up to 150mg) once daily

Standby antibiotic supply ^4,5

Standby antibiotics should be supplied if immediate access to medical care is not available (e.g. whilst on holiday or if living in remote areas). In this circumstance if a patient with hyposplenia/asplenia develops a fever (temp > 38°C) or rigors or is acutely unwell, they should commence the standby antibiotic immediately and seek urgent hospital/medical review.

Age at diagnosis	Standby antibiotic
All ages	< 1 year Amoxicillin /Clavulanate 25mg/kg/dose of amoxicillin component (to a maximum of 875mg) twice daily (use DUO forte or DUO 400 preparations)
If penicillin allergic	Clarithromycin 7.5mg/kg/dose twice daily OR Clindamycin 10mg/kg/dose three times daily

6. Travel

All hyposplenic/asplenic patients travelling to developing countries may be at risk of Plasmodium falciparum malaria, Salmonella infection and Babesiosis (rare tick infection). Infectious Diseases advice should be sought on antimalarial prophylaxis, mosquito avoidance and additional travel vaccines required prior to travel.

7. Animal bites

There is an increased risk of severe sepsis following dog, cat or other animal bites/severe scratches (e.g. due to Capnocytophaga canimorsus, streptococcal sp, anaerobic bacteria). Early medical attention and antibiotic prophylactic treatment with Augmentin duo (Amoxycillin/clavulanic acid) is recommended.

References

1. Spelman D, Buttery J, Daley A et al. Guidelines for the prevention of sepsis in asplenic and hyposplenic patients. Internal Medicine Journal. 2008. 38 pp349-356.
2. Davies, JM, Lewis, PN et al. Review of guidelines for the prevention and treatment of infection in patients with an absent or dysfunctional spleen. British Journal of Haematology. 2012.155.pp308-317.
3. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook, Australian Government Department of Health, Canberra, 2018. Accessed from: https://immunisationhandbook.health.gov.au/
4. Spleen Australia. Medical Guidelines for Individuals with Asplenia or Hyposplenism. February 2016
5. Royal Children’s Hospital. Paediatric Asplenia/Hyposplenia Guidelines: Melbourne July 2014

Approved by:	PCH Clinical Practice Advisory Committee	Date:	20 Sep 2018
Endorsed by:	Executive Director, Nursing Services	Date:	10 Oct 2018
		Review date:	Sep 2021

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