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ASPLENIC TRAVELLERS - Sickle cell disease or splenectomy
What is the danger associated with asplenia?
These people are susceptible to quick overwhelming infection with encapsulated bacteria (meningococcus, pneumococcus, Hemophilus influenza) and intracellular infection (malaria).
What do they need beyond the usual preparation?
1. Extra vaccines: Menactra, Prevnar, Pneumovax-23
2. On-hand antibiotics in case of sudden severe infection: Clavulin 875 mg q12h x 7-10 days
3. Note: Malaria in sickle cell disease is particularly bad. (Sickle cell trait protects to some extent)
The rest of this document gives doses, pediatric doses and elaborates on the above recommendations.
Vaccines to avoid
None, but vaccines may work less well (CIG)
- Hepatitis B: sickle cell could require transfusion, so immunize
Additional vaccines recommended
Prevnar - Gve one dose only if never had a dose (Covered from age 50 and up)
Pneumovax-23: Give if never given or as a single 5 year booster; give it at least 2 mo after Prevnar (Covered age 2 yrs and up)
Menactra: Give if never had it, 2 doses 2 months apart. 5 year boosters. (Covered age 9 mo to 55 yrs by Ont MOH)
Pediatric doses and more information
- Children aged 2 to 11 months should receive 3 doses of Menactra given 2 months apart (minimum 4 weeks apart but then a 4th dose is needed). The Ontario Ministry of Health covers all doses and boosters q3-5 yrs but only from age 9 months on and only Menactra.
People age 1 yr to 55 yrs should receive 2 doses of Menactra™ vaccine given at least 2 months (minimum 4 weeks) apart and booster dose q3-5 years up to age 6 and q5yrs from age 7 yrs. Both doses and boosters are covered by the Ontario Ministry of Health, only Menactra.
Adults aged 56 years and over should receive 2 doses of Menactra® or Menveo™ 8 weeks apart and booster doses as outlined below. Conjugated quadrivalent meningococcal vaccine are not authorized for use in people 56 years of age and over; however, based on limited evidence and expert opinion, that vaccine use is considered appropriate. Not covered by the Ontario Ministry of Health.
Source: primarily Ontario Ministry of Health Dec 2016
Pneumonia conjugate 13-valent vaccine (Prevnar)
Free from Ontario MOH for adults age 50+ with asplenia
Children age 2 months to 1 year
Routine immunization at 2, 4 and 12 months of age. With asplenia, add a dose at 6 months of age.
Children between 1 year and less than 2 yrs
2 doses at least 2 months apart.
No polysaccharide Pneumo-23.
Adults and children 2 yrs and older
Even if a child received all recommended doses of Pneu-C-7 or Pneu-C-10 vaccine in the past, they should be given Pneu-C-13 vaccine as soon as possible.
Pneumonia polysaccharide 23-valent vaccine
Free from Ontario MOH for people age 2 yrs and up with asplenia, including 1 booster.
Adults and children 2 yrs and older
One dose 2 months after conjugate vaccine-13 valent Prevnar..
Booster: One lifetime booster dose 5 years later. Give it 3 years later for those who were 10 years of age or younger at the time of initial immunization.
Both covered from age 2 yrs by Ontario MOH.
Pneu-C-13 vaccine primes the immune system and should be followed by the broader spectrum, though less immunogenic, pneumococcal polysaccharide 23-valent vaccine (Pneu-P-23) for supplemental protection.
Sources: Ontario MOH and UpToDate
Susceptible hyposplenic or asplenic individuals should receive two doses of univalent varicella vaccine, at least 3 months apart (instead of 6 weeks apart as routinely recommended for adolescents and adults). Careful with this one. Do not give if seriously immunocompromised or
after bone marrow transplant.
Note that malaria can be more severe, so prophylaxis is very important. (CDC YB 2014)
Note that Howell-Jolly bodies (partly nucleated red cells) will be present and could fool a technician checking for malaria, resembling malaria.
They should wear a medic-alert bracelet.
Clavulin (amoxicillin, clavulanate) 875 mg q12h x 7-10 days as standby antibiotic to be taken if fever. The concern is sudden overwhelming post-splenectomy infection (OPSI).
Some advise prophylaxis, others prefer standby antibiotics.
If penicillin allergy, don't prescribe Clavulin. Prescribe a quinolone - see next paragraph.
From UTD: 2018
Recommended antibiotics for coverage of S. pneumoniae and H. influenzae include amoxicillin-clavulanate, cefuroximeaxetil, or, for adolescents and adults only, an extended-spectrum fluoroquinolone (levofloxacin, moxifloxacin, or gemifloxacin).
(Levofloxacin was on back-order 7/18 in Ottawa)
Overwhelming sepsis begins with a flu-like illness that can include vomiting and diarrhea. It is imperative that antibiotics be started at once.
Give the traveller a printed copy of the following section on treatment of OPSI, to hand to the treating MD abroad:
For onset of OPSI (overwhelming post-splenectomy infection), UpToDate October 2016 UTD recommendation is:
Initial empiric therapy for adults should include vancomycin (15 to 20 mg/kg intravenously [IV] every 8 to 12 hours [not to exceed 2 g per dose or a total daily dose of 60 mg/kg initially; adjust dose to achieve vancomycin serum trough concentrations of 15 to 20 mcg/mL]) plus meningitis doses of either ceftriaxone (2 g IV every 12 hours) or cefotaxime (2 g IV every 4 to 6 hours) due to concerns regarding possible penicillin-resistant pneumococcal infection and beta-lactamase–producing H. influenzae