Vaccination among splenectomy patients: can unavailability or ignorance justify failure in administration?

Introduction

The spleen has a crucial role in haematological and immunological function. It plays a dual role in immunity; it contributes to the immediate, nonspecific responses of innate immunity by phagocytosis, complement activation, and cytokine production. Simultaneously, it is integral to the specific, adaptive immune responses by facilitating antigen presentation, T and B cell activation leading to antibody production. This makes it a crucial organ for coordinating and integrating both arms of the immune system's response to infection and other challenges to the body's health. ¹

Splenectomy is performed both as an elective or emergency procedure. Haematologic complications are the most prevalent elective indication for splenectomy, whereas serious trauma is the most common reason for an emergency procedure. ² Asplenic patients have a compromised immune system because the spleen is not present to produce antibodies or remove pathogens, antibody-coated or damaged blood cells.

As a result, splenectomised patients have greater challenges recovering from infections including pneumonia, meningitis, sepsis, nosocomial infections, babesiosis, malaria, and other parasite illnesses as well as bacterial infections. ³ Asplenia is a major risk factor for invasive infections, especially those caused by encapsulated bacteria such as Streptococcus pneumoniae (which causes >50% of infections), Haemophilus influenzae type b (Hib), and Neisseria meningitidis. ⁴ A splenectomized person becomes more prone to respiratory, urinary, and meningeal infections. Bacteraemia and overwhelming post-splenectomy infection (OPSI), a severe episode of sepsis, can be caused by bacterial seeding from infection sites with a rapid onset and high fatality rate. The prognosis of OPSI patients is improved by prompt diagnosis, rapid therapy, and regular monitoring after splenectomy. ⁵ In splenectomised patients, 30% of OPSI occurs within the first year after surgery and 50% within the first two years. ⁶

Vaccines, highly recommended, should be provided at least two weeks before surgery in situations where it is elective or two weeks following a surgical intervention. ⁷

Conjugate pneumococcal and meningococcal vaccines elicit a T-cell dependent immune response and are more immunogenic than vaccines with polysaccharides alone; they induce long-term protection, immunologic memory and have a boosting effect with a better immunologic response when used for priming; conjugated vaccines should be preferred.^8–9

Among asplenic patients, influenza vaccination reduces by 54% the risk of death compared to unimmunized asplenic persons, ¹⁰ and even those previously vaccinated with a primary cycle of Tetanus, Diphtheria & Poertussis (TdaP), one booster dose is recommended. ¹¹

Considering the low risks of reactions and the low cost of anti-Hib vaccine, and the lack of access to the assessment of post-vaccination antibodies, it is suggested that vaccination against Haemophilus Influenzae type b in asplenic and hyposplenic subjects, regardless of the history of vaccinations should be considered, in order to increase antibody titres. ¹² (Table 1)

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Table 1.

Centers for Disease Control and Prevention (CDC) guidelines for both emergency and elective splenectomy.

S.No	Vaccines	Dose
1	Anti-pneumococcal vaccination	13-valent conjugate anti-pneumococcal vaccine (PCV13) dose followed at least 8 weeks later by a 23-valent polysaccharide anti-PCV (PPSV23) dose
2	Anti-Haemophilus influenzae type b vaccine	Elective splenectomy- 1 dose, preferably at least 14 days before splenectomy
3	Anti-meningococcal ACYW135 and anti-meningococcal B vaccines	2 doses 8 weeks apart and a booster dose once every 5 years and 2 or 3 doses depending on the employed vaccine
4	TdaP (Tetanus, diptheria and acellular pertussis)	1 dose Tdap, then Td or Tdap booster every 10 yrs
5	MMR (Measles, Mumps and Rubella)	1 or 2 doses depending on indication
6	Varicella	2-dose series recombinant zoster vaccine 2–6 months apart (minimum interval: 4 weeks)

Survey of vaccination after splenectomy in the literature

A study from Italy in 166 patients in 2016 noted that none had received any immunizations while in hospital. ¹³ Another Italian study noted that only two thirds received at least one of the four vaccines, and the overall mortality was significantly greater in the unvaccinated group. Further it was remarked that of 21 reported cases of OPSI, eight were fatal and five were potentially vaccine-preventable. ¹⁴ Similar low vaccination rates were noted in the USA:

only 15% of 253 received all the recommended immunizations against S pneumoniae, although 95% did receive at least 1 dose of pneumococcal vaccine. Many (3–10%) received redundant immunizations not in accordance with CDC recommendations. ¹⁵

Discussion

Splenectomized patients face significant barriers to vaccination, with wide regional disparities and systemic gaps. A study from South India reported that only 46.2% of patients received at least one recommended vaccine, with rural populations particularly disadvantaged due to poor cold-chain maintenance and lack of trained personnel. ¹⁶ Financial constraints further limit access, as costly vaccines lead to out-of-pocket surgical expenses. It is anticipated in many studies that the standard recommendations for the care of splenectomised patients were not adhered to. ¹⁷

Healthcare providers have an ethical duty to prevent OPSI, yet systemic failures, viz. stock-outs, poor documentation, fragmented communication, hinder timely vaccination. Such gaps are likely worse in LMICs.

In India, vaccine scarcity and substantial expenses are also key contributors to the low immunization rate. ¹⁸ Moreover, they are not covered by the universal immunization program, which also protects against polio, Tuberculosis, and hepatitis B.

Although the Pentavalent vaccine, introduced in 2011, ¹⁹ includes Hib, its role in unvaccinated adults with asplenia remains uncertain. Similarly, Tdap is recommended, but adult-specific data are lacking, underscoring the need for further research.^20,21

Conclusion

Ensuring post-splenectomy vaccination is an ethical obligation for healthcare providers and institutions. Persistently low coverage reflects systemic and economic barriers rather than patient refusal, raising concerns of distributive justice and accountability. Missed vaccinations are preventable and highlight failures in continuity of care. We recommend:

Mandatory vaccination counseling and documentation for all splenectomy cases.

Bridging the gap between guidelines and practice requires systemic integration, ethical vigilance, and sustained political will.