People with asplenia and hyposplenia

• People with asplenia (absent spleen) or hyposplenia (impaired splenic function) are at risk of life-threatening infections caused by encapsulated bacteria.
• These people should receive all recommended vaccines, including seasonal influenza vaccination, and additional doses of meningococcal, pneumococcal and Hib (Haemophilus influenzae type b) vaccines.
• In cases of planned splenectomy, scheduled vaccinations should ideally be completed at least 2 weeks before surgery.
• After emergency splenectomy, any vaccinations that remain outstanding should ideally be administered at least 2 weeks after surgery, but can be given once the person is stable and before discharge.

For more details about the immunosuppressive potential of various medications and medical conditions, see:

• Table. Types of medical conditions and immunosuppressive therapy and associated levels of immunocompromise
• Table. Immunosuppressive potential of cancer and organ rejection therapies
• Table. Immunosuppressive potential of conventional (non-biological) immunosuppressive therapies
• Table. Immunosuppressive potential of small molecule targeted therapies
• Table. Immunosuppressive potential of biological therapies
• Table. Immunosuppressive potential of corticosteroids
• Table. Immunosuppressive potential of certain medical conditions

Anatomical asplenia means a person does not have a spleen. Their spleen may have been surgically removed or, in rare cases, they may have been born without a spleen.

Functional asplenia or hyposplenia means a person’s splenic function is impaired. This is usually caused by congenital disorders or systemic diseases,¹ such as sickle cell disease, thalassaemia, coeliac disease, cirrhosis and some cancers.

People with anatomical or functional asplenia have a lifelong increased risk of serious bacterial infections,^1,2 particularly due to encapsulated bacteria.³ This includes a risk of systemic infection with:

• Streptococcus pneumoniae
• Neisseria meningitidis
• Haemophilus influenzae type b 
   

Antibody responses to vaccination are usually adequate in most asplenic patients. But to optimise the immune response to vaccination, people undergoing a planned splenectomy are recommended to receive all scheduled vaccines at least 2 weeks before splenectomy, when possible. This includes any additional doses, as per Table. Recommendations for vaccination in people with asplenia or hyposplenia by age at the time of asplenia or hyposplenia diagnosis).^4-7

After an emergency splenectomy, people should wait 2 weeks before receiving vaccines.⁸ Antibody responses, especially to pneumococcal vaccines, appear to be better when these vaccines are administered 2 weeks after surgery, rather than earlier.^4,9 However, if there is concern the patient may not return or may be lost to follow-up after splenectomy, vaccines may be given once the person is stable and before hospital discharge.

The risk of infection after splenectomy is lifelong. However, the immediate post-splenectomy years pose the greatest risk, with nearly 30% of infections occurring within the first year, and 50% within the first 2 years after splenectomy.¹

Patients with non-surgical asplenia or hyposplenia should receive the recommended vaccinations as soon as the impaired splenic function is recognised, according to the age-appropriate schedule.

People with asplenia or hyposplenia can safely receive all vaccines, including live vaccines.

It is important that people with asplenia or hyposplenia remain up to date with all routinely recommended vaccines. This includes any booster doses, such as booster doses of dTpa (reduced antigen content diphtheria-tetanus-acellular pertussis) vaccine that are recommended in adulthood.

It is particularly important that people with asplenia or hyposplenia receive the following additional vaccines:

• meningococcal vaccines — a complete primary course of both MenACWY and MenB vaccines, and additional booster doses (see Table. Recommendations for vaccination in people with asplenia or hyposplenia by age at the time of asplenia or hyposplenia diagnosis)
• pneumococcal vaccines — a complete course of pneumococcal conjugate vaccine, and additional doses of conjugate and polysaccharide vaccines (see Table. Recommendations for vaccination in people with asplenia or hyposplenia by age at the time of asplenia or hyposplenia diagnosis)
• Hib vaccine — an age-recommended course of Hib-containing vaccine, and an additional dose of hib-containing vaccine at age 5 years (or whenever they become asplenic or hyposplenic)
• influenza vaccine — an annual influenza vaccine according to the recommended schedule. This is particularly important to reduce the risk of secondary bacterial infections after influenza in people with asplenia or hyposplenia.

As well as immunisation, providers should consider the need for antibiotic prophylaxis and the availability of empiric antibiotics in the outpatient setting. Providers should also educate patients and their families about the signs of bacterial infection, and the need to seek urgent medical care if these signs appear.

Travellers with asplenia or hyposplenia should seek advice on receiving additional vaccinations or booster doses, especially when travelling to countries where infectious diseases are more common.¹⁰ When travelling, they should carry a note from their physician stating their diagnosis, associated risks and a management plan in case they become ill. For travel to malaria-endemic areas, they should also receive malaria prophylaxis because of the higher risk of life-threatening malaria.^11,12

1. Bonanni P, Grazzini M, Niccolai G, et al. Recommended vaccinations for asplenic and hyposplenic adult patients. Human Vaccines and Immunotherapeutics 2017;13:359-68.
2. Schutze GE, Mason EO, Jr., Barson WJ, et al. Invasive pneumococcal infections in children with asplenia. Pediatric Infectious Disease Journal 2002;21:278-82.
3. Lenti MV, Luu S, Carsetti R, et al. Asplenia and spleen hypofunction. Nat Rev Dis Primers 2022;8:71.
4. Shatz DV, Schinsky MF, Pais LB, et al. Immune responses of splenectomized trauma patients to the 23-valent pneumococcal polysaccharide vaccine at 1 versus 7 versus 14 days after splenectomy. Journal of Trauma 1998;44:760-5.
5. Forstner C, Plefka S, Tobudic S, et al. Effectiveness and immunogenicity of pneumococcal vaccination in splenectomized and functionally asplenic patients. Vaccine 2012;30:5449-52.
6. Langley JM, Dodds L, Fell D, Langley GR. Pneumococcal and influenza immunization in asplenic persons: a retrospective population-based cohort study 1990–2002. BMC Infectious Diseases 2010;10:219.
7. Smets F, Bourgois A, Vermylen C, et al. Randomised revaccination with pneumococcal polysaccharide or conjugate vaccine in asplenic children previously vaccinated with polysaccharide vaccine. Vaccine 2007;25:5278-82.
8. Rubin LG, Levin MJ, Ljungman P, et al. 2013 IDSA clinical practice guideline for vaccination of the immunocompromised host. Clinical Infectious Diseases 2014;58:309-18.
9. Shatz DV, Romero-Steiner S, Elie CM, Holder PF, Carlone GM. Antibody responses in postsplenectomy trauma patients receiving the 23-valent pneumococcal polysaccharide vaccine at 14 versus 28 days postoperatively. Journal of Trauma 2002;53:1037-42.
10. Salvadori MI, Price VE, Canadian Paediatric Society, Infectious Diseases Immunization Committee. Preventing and treating infections in children with asplenia or hyposplenia. Paediatr Child Health 2014;19:271-8.
11. Bach O, Baier M, Pullwitt A, et al. Falciparum malaria after splenectomy: a prospective controlled study of 33 previously splenectomized Malawian adults. Transactions of the Royal Society of Tropical Medicine and Hygiene 2005;99:861-7.
12. Kho S, Andries B, Poespoprodjo JR, et al. High risk of Plasmodium vivax malaria following splenectomy in Papua, Indonesia. Clinical Infectious Diseases 2019;68:51-60.