* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Download Splenectomy Guideline - Gloucestershire Hospitals NHS Foundation
Survey
Document related concepts
Leptospirosis wikipedia , lookup
Carbapenem-resistant enterobacteriaceae wikipedia , lookup
Human cytomegalovirus wikipedia , lookup
Influenza A virus wikipedia , lookup
Hepatitis B wikipedia , lookup
Poliomyelitis wikipedia , lookup
Anthrax vaccine adsorbed wikipedia , lookup
Eradication of infectious diseases wikipedia , lookup
Hospital-acquired infection wikipedia , lookup
Meningococcal disease wikipedia , lookup
Transcript
Gloucestershire Hospitals NHS Foundation Trust TRUST GUIDELINE HYPOSPLENISM (Protection of Patients with an Absent or Dysfunctional Spleen) FAST FIND: For summary guidance of this document, see action card ADS1 For the post-splenectomy checklist, including verbal information to be given to patients, see action card ADS2 For written patient information, see - Information for patients who have had their spleen removed or whose spleen does not work properly 1. INTRODUCTION Patients who have been splenectomised or who have a spleen that does not function adequately (hyposplenism) are at risk of overwhelming infection from certain micro-organisms such as capsulate bacteria e.g. Streptococcus pneumoniae, Haemophilus influenzae serotype b and Neisseria meningitidis. This risk can be reduced by the provision of education to the patient, appropriate vaccination and prophylactic antibiotics providing pneumococcal cover. Details of all these are given in these guidelines. These guidelines are equally applicable to hospitalised patients as well as to patients in the community. They are also applicable not only to individuals who have recently had their spleen removed but also to those patients that have been identified at a later date of having hyposplenism regardless of cause. These guidelines are for use on adult patients and children. For the sake of simplicity, in this guideline the term “hyposplenism” will be taken to include asplenism/splenectomy and conditions where the spleen is still present but not fully functional (dysfunctional spleen). Where the terms asplenia/asplenism are used the term is being used solely for conditions where the spleen is absent. 2. DEFINITIONS Word/Term Hyposplenism Asplenism/asplenic Capsulate bacteria 3. Descriptor Absent or reduced splenic function, usually due to surgical removal, congenital aplasia, tumour replacement, or splenic vascular accident. Conditions where the spleen is absent Bacterial with an outer covering made of polysaccharide ROLES AND RESPONSIBILITIES Post/Group Medical staff Nursing staff Pharmacy staff HYPOSPLENISM ISSUE DATE: June 2015 Details Prescribing vaccines and prophylactic antibiotics for the protection of patients (adults and paediatric) with an absent or dysfunctional spleen Provision of patient information Identifying patients who have had a splenectomy Provision of patient information Dispensing and checking of vaccines and prophylactic antibiotics Provision of patient information PAGE 1 OF 13 REVIEW DATE: June 2017 4. HYPOSPLENISM CRITERIA Patients who have had their spleen removed by elective or emergency surgery fall under this guideline. Individuals (adults and children) who have the following conditions may be hyposplenic: Homozygous sickle cell disease Coeliac disease Inflammatory bowel disease Active chronic graft-versus-host disease Those who have undergone post therapeutic splenic irradiation Unfortunately there is no routinely available and reliable way of assessing splenic function. The presence of Howell-Jolly bodies may be taken to indicate hyposplenism in the appropriate clinical circumstances, but their absence does not exclude hyposplenism. Patients require clinical evaluation of the likelihood of hyposplenism and this should be discussed with the appropriate specialist if there is uncertainty. 5. VACCINATION Normal inoculations, including live vaccines, can be given safely to children or adults with an absent or dysfunctional spleen and vaccination against a range of potential pathogens has become accepted practice. 5.1 Risks of infection Hyposplenic individuals, especially young children, have a high risk of invasive infections caused by encapsulated organisms (particularly Streptococcus pneumoniae, Haemophilus influenzae serotype b (Hib) and Neisseria meningitidis) and, at the same time, have an inherently reduced ability to mount protective antibody responses to polysaccharide antigens, which may result in vaccine failure. There are over 90 different serotypes of S. pneumoniae, of which at least 30 can cause invasive disease in humans. 5.2 When to give vaccines Vaccinations are advocated in the following circumstances: 5.3 Elective Splenectomy - Vaccination should take place at least two weeks before the planned splenectomy. DoH guidance indicates vaccination to be optimal if performed 4-6 weeks before the splenectomy but also advises that if the splenectomy needs to be performed more urgently it should not be deferred to allow this 4-6 weeks interval to be achieved Emergency/Unplanned Splenectomy – Vaccine is most effective if performed at least 14 days after surgery. This requires careful coordination between hospital clinicians and GPs to ensure all vaccines are given Hyposplenic individuals who have had immunosuppressive chemotherapy or radiotherapy – it is recommended that vaccination is given at least 2 weeks before immunosuppressive therapy is commenced, and/or delayed for three months after therapy has been completed or longer until recovery of adequate immunological function where this can be appropriately assessed Vaccine efficacy The polyvalent polysaccharide pneumococcal vaccine (PPV) provides short-term immunity against 23 pneumococcal serotypes. Despite appropriate efforts, some patients remain unvaccinated, while true vaccine failures also contribute to pneumococcal infection. Failure to mount an antibody response may be genetically determined but is also more common in older patients and those splenectomised for haematological malignancies. A failure to demonstrate a rise in titre of anti-pneumococcal antibody identifies non-responders who are at high risk of invasive pneumococcal disease. Repeat vaccination is safe in responders and the need HYPOSPLENISM ISSUE DATE: June 2015 PAGE 2 OF 13 REVIEW DATE: June 2017 for revaccination may be based on measurement of antibody levels. True non-responders may derive no benefit even from further vaccination attempts with a conjugate vaccine. Unlike polysaccharide vaccines, conjugate vaccines are highly immunogenic in infants as young as 2 months of age, provide higher antibody titres and induce immunological memory. The 7-valent pneumococcal conjugate vaccine (PCV7) was replaced in 2010, by a 13-valent pneumococcal conjugate vaccine (PCV13). PCV13 is more immunogenic than PPV, albeit with a more limited repertoire, and is highly effective in preventing invasive disease caused by the 13 serotypes included in the vaccine. Conjugate vaccines are immunogenic in hyposplenic individuals and have been administered safely both before and after polysaccharide vaccines post-splenectomy, but the optimum scheduling is unknown. However, PCV may have a role in PPV failures, although repeated prior administration of PPV may reduce the response to subsequent PCV administration. 5.4 Schedule for immunisation with conjugate vaccines in individuals with hyposplenism The number of doses and the vaccinations required depend on the age at which the hyposplenism is acquired or diagnosed and their vaccination history. Children under 5 years old Check patient has been vaccinated according to UK schedule (see Appendix 1) Administer vaccines based on age and vaccination history (see Appendix 2) Children over 5 years old and Adults Check patient has been vaccinated according to UK schedule (see Appendix 1) Initial vaccinations (see section 5.2 for when to give in relation to surgery) Hib/MenC conjugate (Menitorix®) 0.5ml IM Pneumococcal polysaccharide (PPV23) 0.5ml IM followed by a booster dose every 5 years Meningitis B (Bexsero®) 0.5ml IM 2 months later MenACWY conjugate(Menveo® or Nimenrix®) 0.5ml IM Meningitis B (Bexsero®) 0.5ml IM See Appendix 3 for further information about vaccines 5.5 Prescribing and administering the vaccines For inpatients the vaccines should be prescribed in the ‘Once only and Pre Anaesthetic Medication’ section on the front of the in-patient prescription chart. All the recommended vaccines are inactivated, so if necessary they can all be given at the same time; however they must be administered at different sites. For children under 2 years, paracetamol should be given orally at a dose of 10-15mg/kg before or at the time of vaccination with Men B (Bexsero). Doses can be repeated every 4 – 6 hours after vaccination if needed. 5.6 Booster Doses Booster doses are only required for pneumococcal polysaccharide vaccine (PPV). Most hyposplenic individuals should be routinely boosted 5 years after the last dose of pneumococcal vaccine. A small number of individuals (particularly those with sickle cell anaemia or lymphoproliferative disorders) should have their pneumococcal antibody levels checked 3 years after the last dose of vaccine. If levels HYPOSPLENISM ISSUE DATE: June 2015 PAGE 3 OF 13 REVIEW DATE: June 2017 are found to be unprotective then boosting would be appropriate. If levels are found to be protective then the levels should be rechecked annually until 5 years after the last dose when a booster should be given routinely. Notes: 5.7 The World Health Organization has recommended a serotype-specific IgG level of at least 0.35 µg/mL as a putative protective threshold following conjugate immunization in young children. The relevance of this threshold for adults, especially older people, is unclear and higher thresholds (e.g. at least 1.0 µg/mL) may be more appropriate. Where individual laboratories have in place validated methods to determine serotype specific anti-pneumococcal antibody levels this may be used to guide decision-making The additional benefit of PCV vaccination in good serological responders to PPV is unclear and PCV vaccination should not therefore be routine in this group. Patients with sub-optimal or no serological response to PPV represent a high-risk group for invasive pneumococcal disease. They may benefit from PCV immunization, 2 doses given 4 weeks apart. Annual influenza vaccination An annual influenza vaccine of the appropriate type is recommended. National guidelines suggest giving influenza vaccine either pre-splenectomy (if planned) or after emergency splenectomy (or as soon as possible after a patient is identified as being hyposplenic). Due to lack of availability of influenza vaccine outside of the influenza season it would be most practical to give the first dose of the vaccine just before the start of the next influenza season (September to December) and annually at this time of year thereafter. 6. PROPHYLACTIC ANTIBIOTICS 6.1 Risk of infection The increased risk of infection in patients with hyposplenism is lifelong, but is highest early after splenectomy, the highest risk being from pneumococcal infection. Other risk factors include: patient under 16 years or over 50 years of age inadequate serological response to pneumococcal vaccination previous invasive pneumococcal disease splenectomy for haematological malignancy (rather than trauma) especially in the context of ongoing immunosuppression patients treated for haematological malignancy, particularly those who have received splenic irradiation patients with active ongoing graft-versus-host disease These factors can be used to stratify patients who are at higher risk of infection. Patients who have had splenectomy for trauma are at greatest risk of infection in the immediate post-operative period and prophylaxis should continue for this period at least. 6.2 Prescribing strategies Lifelong prophylactic antibiotics should be offered to patients considered at continued high risk of pneumococcal infection High risk groups need careful counselling and follow up to ensure lifelong adherence to antibiotic prophylaxis Patients not at high risk should be counselled regarding the risks and benefits of lifelong antibiotics and may choose to discontinue them Lifelong antibiotics have potential disadvantages such as the development of bacterial resistance, side effects including allergy, and may be associated with poor adherence. Patients developing systemic infection (high fever) despite the above measures must be given HYPOSPLENISM ISSUE DATE: June 2015 PAGE 4 OF 13 REVIEW DATE: June 2017 systemic antibiotics and admitted urgently to hospital. 6.3 Prophylactic prescribing regimes Table 4 Drug Indications Patient not penicillin-allergic: Amoxicillin Adults and children over 12 years Children 5 years – 12 years Children under 5 years Phenoxymethylpenicillin (Penicillin V) Adults and children over 5 years Children 1 - 5 years Children under 1 year Patient penicillin-allergic: Erythromycin Adults and children over 8 years Children 2 years – 8 years Children from 1 month 2 years Dose Notes 250 mg od po 125 mg od po 10 mg/kg od po (max dose 125 mg/day) 250 mg bd po 125 mg bd po Penicillin V has no activity against Haemophilus influenzae. Use Amoxicillin if there has been previous invasive Haemophilus disease 62.5 mg bd po 500 mg od po First choice macrolide for prophylaxis, but may cause GI side effects. Consider clarithromycin for these individuals, but it is not licensed for prophylactic use 250 mg od po 125 mg od po Patients can still get severe systemic infections despite the correct use of antibiotic prophylaxis. This needs to be explained to patients and they should also be supplied with therapeutic doses of antibiotics (and instructions on when to use them, see Hyposplenism: Patient information) to be taken as necessary if a “break-through” systemic infection is suspected. 6.4 Supply of therapeutic doses of antibiotics for use as required at home Patients should be given a supply of amoxicillin (or clarithromycin if penicillin-allergic) at therapeutic dose to keep at home. If a patient does become clinically infected despite prophylactic antibiotics they should immediately start taking a therapeutic course of antibiotics and seek urgent medical attention as hospital admission may be required. Table 5: Drug Indications Patient not penicillin-allergic: Amoxicillin Adults and children over 12 years Children 5 – 12 years Children 1 - 5 years Children from 1 month - 1 year Patient penicillin-allergic: Clarithromycin Adults and children over 12 years Children 10 – 12 years (30-40 kg) Children 7 – 9 years (20-29 kg) Children 3 – 6 years (12-19 kg) Children 1 – 2 years (8-11 kg) Children under 1 year ( less than 8 kg) HYPOSPLENISM ISSUE DATE: June 2015 Dose 500 mg tds po 250 mg tds po 125 mg tds po 62.5 mg tds po 500 mg bd po 250 mg bd po 187.5 mg bd po 125 mg bd po 62.5 mg bd po 7.5 mg/kg bd po PAGE 5 OF 13 REVIEW DATE: June 2017 6.5 Treatment of Animal and Human Bite See Trust Antibiotic Guidelines for Animal and Human Bites in Adults and Animal and Human Bites in Children 6.6 “Post Splenectomy” checklist for inpatients Once a patient has been identified as having had or about to have a splenectomy (or after they have been identified as being hyposplenic whilst under the care of a hospital physician or surgeon), carry out the checklist in action card ADS2. 7. RECORD KEEPING AND COMMUNICATION 7.1 Record keeping The following must be documented on the patient’s health records (inpatient and outpatient) and discharge summary for all hyposplenic patients: 7.2 Hyposplenic or asplenic status All administration of vaccines including those due to be given at a later date Communication with primary care The following information must be communicated with the patient’s GP and any other primary, secondary or tertiary care providers: 7.3 Hyposplenic status Information about vaccination courses that will need to be completed in primary care after discharge Information on long-term antibiotic prophylaxis and vaccinations/boosters (including dates and immunity tests, where applicable) Further Information/Contact Numbers Vaccinations Advice on treatment of severe infection 8. Local PCT immunisation coordinator Consultant in Communicable Disease Control, Gloucestershire Health Protection Team Duty Clinical Consultant Microbiologist MONITORING OF COMPLIANCE See POPAM 9. REFERENCES 1. Review of guidelines for the prevention and treatment of infection in patients with an absent or dysfunctional spleen. British Journal of Haematology; 155: 308-317 2. Guidelines for the prevention and treatment of infection in patients with an absent or dysfunctional spleen. BMJ 1996; 312: 430-434. 3. Update of guidelines for the prevention and treatment of infection in patients with an absent or dysfunctional spleen. Clin Med JRCPL 2002; 2: 440-443. Available at: http://www.bcshguidelines.com./pdf/SPLEEN21.pdf 4. Immunisation against Infectious Disease (2013). (“The Green Book”), Department of Health. The Stationery Office. Chapter 7 Immunisation of individuals with underlying medical conditions HYPOSPLENISM ISSUE DATE: June 2015 PAGE 6 OF 13 REVIEW DATE: June 2017 5. Immunisation against Infectious Disease (2013). (“The Green Book”), Department of Health. The Stationery Office. Chapter 11. The UK immunisation schedule. 6. Immunisation against Infectious Disease (2013). (“The Green Book”), Department of Health. The Stationery Office. Chapter 16 Haemophilus influenzae type b (Hib) 7. Immunisation against Infectious Disease (2013). (“The Green Book”), Department of Health. The Stationery Office. Chapter 19 Influenza 8. Immunisation against Infectious Disease (2013). (“The Green Book”), Department of Health. The Stationery Office. Chapter 22 Meningococcal 9. Immunisation against Infectious Disease (2013). (“The Green Book”), Department of Health. The Stationery Office. Chapter 25 Pneumococcal 10. Public health briefing note 2015/024. April 2015. Vaccine error: Use of Infanrix-IPV instead of Infanrix-IPV+Hib for primary immunisation and use of Infanrix-IPV+Hib without reconstitution and administration of the Hib component 11. Summary of Product Characteristics (SPCs) for the listed drugs. Available at www.emc.medicines.org.uk 10. BNF for children 2012-2013 HYPOSPLENISM (PROTECTION OF PATIENTS WITH AN ABSENT OR DYSFUNCTIONAL SPLEEN) – DOCUMENT PROFILE DOCUMENT PROFILE REFERENCE NUMBER CATEGORY VERSION AUTHOR ISSUE DATE REVIEW DETAILS ASSURING GROUP APPROVING GROUP APPROVAL DETAILS CONSULTEES DISSEMINATION DETAILS KEYWORDS RELATED TRUST DOCUMENTS OTHER RELEVANT DOCUMENTS HYPOSPLENISM ISSUE DATE: June 2015 A0326 Clinical 3 Rob Jackson / Philippa Moore 06/2015 06/2017 – review by Antimicrobial Stewardship Committee Trust Policy Assurance Group Antimicrobial Stewardship Committee Policy application: 18/06/2013 Policy approval: Antimicrobial Stewardship Committee 15/05/2013 TPAG approval: 25/06/2013 Version 3 approval by: Antimicrobial Stewardship Committee 17/06/2015 Antimicrobial Stewardship Committee and pharmacy Upload to Policy Site; antibiotic guidelines on the intranet, global email; distribution via pharmacists Hyposplenism, splenectomy, asplenic Action cards ADS1 and ADS2; patient information leaflet on Hyposplenism Local antibiotic guidelines PAGE 7 OF 13 REVIEW DATE: June 2017 Appendix 1 - Current UK Vaccination Schedule WHEN TO IMMUNISE Two months old VACCINES TO BE GIVEN Diptheria, tetanus, pertussis, polio and Hib (DTaP/IPV/Hib) Pneumococcal conjugate (PCV) Rotavirus Three months old Diptheria, tetanus, pertussis, polio and Hib (DTaP/IPV/Hib) Meningococcal C conjugate (MenC) Rotavirus Four months old Diptheria, tetanus, pertussis, polio and Hib (DTaP/IPV/Hib) Pneumococcal conjugate (PCV) Between 12 and 13 months of age (i.e. within a month of the first birthday) Hib/Men C conjugate Pneumococcal conjugate (PCV) Measles, mumps and rubella (MMR) Two years to less than 17 years old. Three years four months old or soon after Influenza (to be given annually) Diptheria, tetanus, pertussis and polio (DTaP/IPV or dTap/IPV) Measles, mumps and rubella (MMR) Girls aged 12 to 14 years old Around 14 years old Human papilloma virus (HPV) Course of two injections at least six months apart Tetanus, diphtheria and polio (Td/IPV) Meningococcal C conjugate (MenC) 65 years old Pneumococcal polysaccharide (PPV) 70 years old Influenza (to be given annually) Shingles HYPOSPLENISM ISSUE DATE: June 2015 PAGE 8 OF 13 REVIEW DATE: June 2017 Appendix 2 - Splenectomy Vaccination Schedule for children under 5 years Age 0 to 2 months (Before 2 month vaccinations given) Immediately MenACWY conjugate followed by a second dose 1 month later Age 2 months Diptheria, tetanus, pertussis, polio and Hib (DTaP/IPV/Hib) Age 3 months Diptheria, tetanus, pertussis, polio and Hib (DTaP/IPV/Hib) Age 4 months Diptheria, tetanus, pertussis, polio and Hib (DTaP/IPV/Hib) Pneumococcal conjugate (PCV) Rotavirus Pneumococcal conjugate (PCV) Meningitis B Rotavirus Age 12 months Hib/MenC conjugate Pneumococcal conjugate (PCV) Measles, mumps and rubella (MMR) Meningitis B Age 14 months Meningitis B Age 2 years Hib/MenC conjugate Pneumococcal conjugate (PCV) MenACWY conjugate Pneumococcal polysaccharide (PPV23) Meningitis B Age 2 to 3 months (After 2 month vaccinations and before 3 month vaccinations) Immediately MenACWY conjugate followed by a second dose 1 month later Age 3 months Diptheria, tetanus, pertussis, polio and Hib (DTaP/IPV/Hib) Age 4 months Diptheria, tetanus, pertussis, polio and Hib (DTaP/IPV/Hib) Meningitis B followed by 2 further doses at monthly intervals Rotavirus Pneumococcal conjugate (PCV) HYPOSPLENISM ISSUE DATE: June 2015 Meningococcal C conjugate (MenC) Age 12 months Hib/MenC conjugate Pneumococcal conjugate (PCV) Measles, mumps and rubella (MMR) PAGE 9 OF 13 REVIEW DATE: June 2017 Age 14 months Meningitis B Age 2 years Hib/MenC conjugate Pneumococcal conjugate (PCV) Pneumococcal polysaccharide (PPV23) MenACWY conjugate Age 3 to 4 months (After 3 month vaccinations and before 4 month vaccinations) Immediately Meningitis B followed by 2 further doses at monthly intervals Age 4 months MenACWY conjugate (at least 1 month after previous MenC vaccine) Diptheria, tetanus, pertussis, polio and Hib (DTaP/IPV/Hib) Pneumococcal conjugate (PCV) Age 12 months Hib/MenC conjugate Age 14 months Meningitis B Age 2 years Hib/MenC conjugate Pneumococcal conjugate (PCV) Pneumococcal conjugate (PCV) Pneumococcal polysaccharide (PPV23) Measles, mumps and rubella (MMR) MenACWY conjugate Age 4 to 6 months (After 4 month vaccinations) Immediately Meningitis B followed by 2 further doses at monthly intervals MenACWY conjugate (at least 1 month after previous MenC vaccine) HYPOSPLENISM ISSUE DATE: June 2015 Age 12 months Hib/MenC conjugate Age 14 months Meningitis B Age 2 years Hib/MenC conjugate Pneumococcal conjugate (PCV) Pneumococcal conjugate (PCV) Pneumococcal polysaccharide (PPV23) Measles, mumps and rubella (MMR) MenACWY conjugate PAGE 10 OF 13 REVIEW DATE: June 2017 Age 6 to 12 months (After 6 month vaccinations and before 12 month vaccinations) Immediately Meningitis B followed by 1 further dose at least 2 months later (second dose may be given with 12 month boosters) Age 12 months Hib/MenC conjugate Age 14 months Pneumococcal conjugate (PCV) Pneumococcal conjugate (PCV) Age 2 years Hib/MenC conjugate Meningitis B MenACWY conjugate MenACWY conjugate (at least 1 month after previous MenC vaccine) Measles, mumps and rubella (MMR) Pneumococcal polysaccharide (PPV23) Inactivated trivalent influenza vaccine at the start of the influenza season. If not previously vaccinated with influenza vaccine then repeat after one month. Then a single annual influenza vaccination. Give by IM injection if under 2 years of age and give Fluenz Tetra (nasal spray) when older than 2 years. Age 12 to 24 months (After 12 month vaccinations) Immediately Meningitis B followed by a second dose 2 months later and a third dose 12-23 months later. Pneumococcal conjugate (PCV) (at least 2 months after PCV given at 12 – 13 months) 2 months later (or immediately if older than 14 months) MenACWY conjugate Age 2 years Hib/MenC conjugate Pneumococcal polysaccharide (PPV23) (at least 2 months after PCV) Inactivated trivalent influenza vaccine at the start of the influenza season. If not previously vaccinated with influenza vaccine then repeat after one month. Then a single annual influenza vaccination. Give by IM injection if under 2 years of age and give Fluenz Tetra (nasal spray) when older than 2 years. HYPOSPLENISM ISSUE DATE: June 2015 PAGE 11 OF 13 REVIEW DATE: June 2017 Age 24 months to 5 years Immediately 2 months later HiB/Men C conjugate Meningitis B Pneumococcal conjugate (PCV) MenACWY conjugate Meningitis B Pneumococcal polysaccharide (PPV23) Fluenz Tetra (intra nasal) at the start of the influenza season. If not previously vaccinated with influenza vaccine then repeat after one month. Then repeat annually. Age 5 years to 9 years For other vaccinations – see ADS1 as for adults Fluenz Tetra (intra nasal) at the start of the influenza season. If not previously vaccinated with influenza vaccine then repeat after one month. Then repeat annually. HYPOSPLENISM ISSUE DATE: June 2015 PAGE 12 OF 13 REVIEW DATE: June 2017 Appendix 3 – Notes on vaccines ADMINISTRATION DETAILS VACCINE BRAND NAME Diptheria, tetanus, pertussis, polio and Hib (DTaP/IPV/Hib) Meningitis B Pediacel® Single 0.5ml dose IM (Sanofi Pasteur MSD) or Infanrix-IPV+Hib® (GlaxoSmithKline) Please note Hib component of Infanrix-IPV+Hib® is supplied in a separate glass vial that must be reconstituted with the pre-filled syringe containing diphtheria, tetanus, acellular pertussis and inactivated poliomyelitis antigens prior to administration. Repevax® Single 0.5ml dose IM (Sanofi Pasteur MSD) or Infanrix IPV® (GlaxoSmithKline) Menitorix ® Single 0.5ml dose IM (GlaxoSmithKline) Gardasil® (Sanofi Pasteur Single 0.5ml dose IM MSD) or Cervarix® (GlaxoSmithKline) Live attenuated Single application in each intranasal nostril of 0.1ml vaccine - Fluenz Tetra® (AstraZeneca) Multiple different brands Single 0.5ml dose IM Priorix® Single 0.5ml dose IM (GlaxoSmithKline) or (Priorix) MMRVaxPro® (Sanofi Single dose IM Pasteur MSD) (MMRVaxPro) Menveo® (Novartis) or Single 0.5ml dose IM Nimenrix ® (GlaxoSmithKline) Bexsero® (Novartis) Single 0.5ml dose IM Meningococcal C conjugate (MenC) NeisVac-C® (Pfizer) or Menjugate Kit® (Novartis) Single 0.5ml dose IM Pneumococcal conjugate (PCV) Pneumococcal polysaccharide (PPV23) Prevenar 13® (Pfizer) Single 0.5ml dose IM Pneumococcal Polysaccharide Vaccine Sanofi Pasteur MSD (Previously Pneumovax II) Rotarix ® (GlaxoSmithKline) Zostavax® (Sanofi Pasteur MSD) Revaxis® (Sanofi Pasteur MSD) Single 0.5ml dose IM or SC Diptheria, tetanus, pertussis and polio (DTaP/IPV or dTap/IPV) Hib/Men C conjugate Human papilloma virus (HPV) Influenza (nasal spray) Influenza (injection) Measles, mumps and rubella (MMR) MenACWY conjugate Rotavirus Shingles Tetanus, diphtheria and polio (Td/IPV) HYPOSPLENISM 13 ISSUE DATE: June 2015 Single dose orally Single 0.65ml dose SC Single 0.5ml dose IM PAGE 13 OF REVIEW DATE: June 2017