Download Splenectomy Guideline - Gloucestershire Hospitals NHS Foundation

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
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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
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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
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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
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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)
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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
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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
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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
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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
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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
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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
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Meningococcal C
conjugate (MenC)
Age 12 months
Hib/MenC
conjugate
Pneumococcal
conjugate (PCV)
Measles, mumps
and rubella (MMR)
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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
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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.
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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.
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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)
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Single dose orally
Single 0.65ml dose SC
Single 0.5ml dose IM
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