Vaccination Guidelines for Post-Splenectomy Patients

Introduction to Vaccination

Patients should receive the varicella vaccine only if there is no evidence of prior immunity, and the zoster vaccine should not be administered at this time due to recent immunocompromised state, as recommended by the Infectious Diseases Society of America 1
The Centers for Disease Control and Prevention recommends determining the patient's immunity to varicella-zoster virus before deciding on vaccination, through serology for VZV antibodies (IgG) and considering clinical history of previous varicella or herpes zoster 1

The varicella vaccine (monovalent) should be administered in 2 doses, separated by 4 weeks, as recommended by the American Academy of Pediatrics 2
Vaccination should be delayed until the patient is at least 3 months post-splenectomy to ensure a better immune response, according to the Infectious Diseases Society of America 1
The combined MMRV vaccine should not be administered as it contains 7 times more VZV than the monovalent vaccine, as stated by the Centers for Disease Control and Prevention 1

The Shingrix (RZV) vaccine, a non-live recombinant vaccine, may be considered after the patient is more stable immunologically, although the exact timing is not specified in the provided references 2
The Advisory Committee on Immunization Practices (ACIP) recommends beginning zoster vaccination at age 60 years, as Zostavax (ZVL) is a live-attenuated vaccine with decreasing efficacy with increasing age (only 18% effective in those ≥80 years) 2
Recombinant zoster vaccine (Shingrix) is preferred over Zostavax for patients with prior history of shingles due to higher efficacy across all age groups (91.3% in adults ≥70 years vs. 18% with Zostavax) 2
Shingrix has a longer duration of protection and a non-replicating nature, making it safer in older adults 2
Shingrix is administered as 2 doses, 2-6 months apart, and can be safely given to patients who have previously had herpes zoster, but ensure the patient is not severely immunocompromised before administering any zoster vaccine 2

Splenectomy generates an immunocompromised state that increases the risk of severe infections, especially in the first months post-surgery, as reported by the Clinical Infectious Diseases journal 1, 3
Live vaccines, such as the varicella vaccine (Varivax), are contraindicated in highly immunocompromised patients but may be administered in patients with moderate immunocompromise after evaluating the risk-benefit ratio, according to the Infectious Diseases Society of America 1, 4
The live zoster vaccine (ZOS/ZVL) should NOT be administered to highly immunocompromised patients due to risk of disseminated viral infection, as per the Clinical Infectious Diseases guidelines 1, 5

Patients who have undergone splenectomy require a complete vaccination schedule, including:
These vaccines should be administered before considering the varicella vaccine, as stated by the American College of Physicians 1, 3

If exposure to VZV occurs and the patient is seronegative, varicella-zoster immune globulin (VZIG) should be considered within 10 days of exposure, as recommended by the Centers for Disease Control and Prevention 4, 6
Patients should avoid contact with individuals who have active varicella or herpes zoster during the immunosuppression period, according to the Infectious Diseases Society of America 6

The National Comprehensive Cancer Network recommends using the recombinant zoster vaccine (RZV) for adults ≥18 years who are immunocompromised and at increased risk for herpes zoster 7
RZV is safe and immunogenic in HIV-infected adults on stable antiretroviral therapy, with a recommended CD4 count of ≥200 cells/mm³ for optimal immune response 1
For planned transplantation, administer RZV ≥4 weeks before beginning immunosuppressive therapy if possible, according to the Clinical Infectious Diseases guidelines 1
For patients undergoing chemotherapy, consider administering RZV before starting treatment when possible, and for those already on treatment, RZV can be given when clinically stable 7
Ensure patients receive both doses of RZV for optimal protection, as incomplete vaccination series may reduce efficacy 7
The National Comprehensive Cancer Network recommends RZV after recovery to prevent recurrence of herpes zoster, particularly in adults aged ≥50 years 7
RZV is recommended for adults ≥50 years, administered as 2 doses given 2-6 months apart, for future prevention of herpes zoster, and for patients who have previously had herpes zoster, and for those who previously received the live-attenuated zoster vaccine (ZVL), RZV should be given at least 2 months after the ZVL dose 7