What vaccines should be given and how soon before a splenectomy?

Pre-Splenectomy Vaccination Protocol

All vaccines should be administered at least 2 weeks (ideally 2-6 weeks) before elective splenectomy to ensure optimal antibody response before the patient becomes functionally asplenic. 1, 2

Timing Rationale

The 2-week minimum pre-surgery window is critical because:

• Vaccination at least 2 weeks before surgery produces significantly higher antibody concentrations compared to vaccination at shorter intervals or after surgery. 1, 2
• This timing allows the immune system to mount an optimal response while the spleen is still present and functional. 3, 4
• If preoperative vaccination is impossible (emergency splenectomy), administer all vaccines at least 14 days postoperatively once the patient's condition is stable. 1, 5

Required Vaccines and Administration Protocol

Pneumococcal Vaccines (Sequential "Prime-Boost" Strategy)

For vaccine-naïve patients aged ≥2 years:

• First: Administer PCV13, PCV15, or PCV20 (conjugate vaccine). 1, 2
• Second: Give PPSV23 at least 8 weeks after the conjugate vaccine—never simultaneously. 1, 6
• This sequential approach produces superior antibody responses compared to PPSV23 alone. 1
• Administer a second dose of PPSV23 five years after the first dose. 1, 2
• Revaccinate with PPSV23 every 5-10 years for lifelong protection. 3, 1

Meningococcal Vaccines (Both MenACWY and MenB Required)

MenACWY Protocol:

• Administer 2 doses of MenACWY vaccine given at least 8 weeks apart (not a single dose) for patients aged ≥10 years. 1, 6
• This is a critical distinction—asplenic patients require the enhanced 2-dose series, unlike routine young adults who receive only one dose. 1
• Revaccinate with MenACWY every 5 years for life. 1, 2

MenB Protocol:

• Administer MenB vaccine series: Either MenB-FHbp (3 doses at 0,1-2, and 6 months) OR MenB-4C (2 doses at least 1 month apart). 1
• MenB booster: Single dose at 1 year after primary series, then every 2-3 years. 1, 2
• MenB vaccination is mandatory, not optional, due to 40-70% mortality rates from meningococcal infections in asplenic patients. 1, 6

Haemophilus Influenzae Type b (Hib)

• Administer one dose of Hib vaccine to all unvaccinated asplenic persons aged ≥5 years. 1, 6
• No revaccination needed if the patient completed the childhood Hib series. 1
• Timing should follow the same 2-week pre-surgery guideline. 1

Influenza Vaccine

• Annual inactivated influenza vaccine (IIV) for all asplenic patients aged ≥6 months. 1, 6
• Never use live attenuated influenza vaccine (LAIV/nasal spray) in asplenic patients. 1, 6
• Influenza vaccination reduces the risk of secondary bacterial infection. 3

Critical Pitfalls to Avoid

Common errors that compromise patient safety:

• Do NOT treat asplenic patients like routine adults—they require the enhanced 2-dose MenACWY series, not a single dose. 1
• Do NOT skip MenB vaccination—it is mandatory for asplenic patients, not optional. 1, 6
• Do NOT give PPSV23 and PCV13 simultaneously—wait at least 8 weeks between them. 1, 6
• Do NOT forget lifelong revaccination—protection wanes and infection risk persists for life, with cases of overwhelming infection reported more than 20 years after splenectomy. 3, 1
• Do NOT use MenACWY-D in children <2 years with asplenia—it reduces pneumococcal vaccine response. 1

Special Populations

Patients who received rituximab:

• Patients who received rituximab in the previous 6 months may have suboptimal vaccine response. 2
• Vaccination should be reassessed once B-cell recovery has occurred. 2

Children under 2 years:

• Children have inherently reduced ability to mount antibody responses. 3
• Reimmunization should be considered after 2 years in those remaining at risk. 3

Essential Non-Vaccine Preventive Measures

Beyond vaccination, asplenic patients require:

• Lifelong prophylactic antibiotics (phenoxymethylpenicillin), with highest priority in the first 2 years post-splenectomy. 3, 1
• Emergency standby antibiotics (amoxicillin) for home use at first sign of fever, malaise, or chills. 3, 1
• Patient education about lifelong infection risk and need for immediate medical attention for fever >101°F (38°C). 1, 2
• Medical alert identification (Medic-Alert disc and card) indicating asplenic status. 3, 2
• Formal notification of primary care providers about the patient's asplenic status to ensure appropriate ongoing care. 3, 2

Risk Magnitude Justifying These Measures

• The lifelong risk of overwhelming post-splenectomy infection (OPSI) carries mortality rates of 30-70%. 1, 6
• Streptococcus pneumoniae accounts for approximately 50% of OPSI cases. 1
• Though most infections occur within the first two years after splenectomy, up to a third may manifest at least five years later. 3
• The risk of dying from serious infection is clinically significant and almost certainly lifelong. 3