Disclosure Statement. Encapsulated Bacteria. Functions of the Spleen 10/25/2017. Pharmacist Learning Objectives

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1 Pharmacist Learning Objectives No Spleen? No Problem. A Review of Vaccinations Indicated for the Asplenic Patient SCSHP Fall Meeting October 26, 2017 Explain the rationale for vaccinations in Select the appropriate vaccines for the asplenic patient Identify the ideal timing of specified vaccinations Alyson G. Wilder, PharmD, BCPS Assistant Professor of Pharmacy Practice Presbyterian College School of Pharmacy Pharmacy Technician Learning Objectives Explain the rationale for vaccinations in Describe the vaccines recommended for Identify methods to assist the pharmacist with enhancing vaccination rates and improving healthcare outcomes Disclosure Statement I have no financial relationships to disclose. I will not discuss off label use and/or investigational use in my presentation. Functions of the Spleen Encapsulated Bacteria Polysaccharide capsule Virulent Destroyed by splenic macrophages knight returns/ knight returns/ 1

2 Patient Case Disorders of the Spleen SM is a 53yo F who was involved in a motor vehicle accident. She was admitted to the ICU. On hospital day 3 it was determined that she would need a non emergent splenectomy due to the injuries sustained from the accident. SM continues to be hemodynamically stable and surgery is scheduled for the next day. Asplenia Hyposplenia Absence of spleen Congenital, functional, surgical Impaired function of spleen Acquired disorder Rubin LG et al. N Engl J Med 2014;371: Overwhelming post splenectomy infection (OPSI) Non specific symptoms Nausea, vomiting, fever Rapidly progressive Fulminant sepsis Coma High mortality rate Up to 50% despite maximal treatment Risk of OPSI Greatest in first 2 years after splenectomy 30% in the first year 50% within the first 2 years Lifetime risk of 5% Risk factors Concomitant hematological disease Age at time of splenectomy Bisharat N et al. J Infect 2001;43(3): Bisharat N et al. J Infect 2001;43(3): Common Pathogens Vaccinations for Asplenic Patients Pneumococcal Meningococcal Haemophilus influenzae type b (Hib) Influenza 2

3 Optimal Timing of Vaccination Recommended Timing of Vaccination Recovery from the stresses of the initial injury Non elective splenectomy On or after post op day 14; at hospital discharge Recovery from surgical intervention Elective splenectomy At least 14 days prior to surgery Ability to mount optimal antibody response Nonfunctional spleen As soon as the diagnosis is made S. pneumoniae More than 90 serotypes Bacteremia, meningitis, pneumonia Cause of over 4,000 deaths each year in US Responsible for more than half of OPSI cases Pneumococcal Vaccines Formulation and sequence based on vaccination history PCV13 (Prevnar ) 13 serotypes Single dose PPSV23 (Pneumovax ) Polysaccharide 23 serotypes IM or SubQ Maximum of 3 doses No history of pneumococcal vaccination (Age 19 64) History of PPSV23 (Age 19 64) History of ONE dose PPSV23 PCV13 (2wk preop or postop) PCSV23 (8wk later) PPSV23 (after age 65) PCV13 (2wk preop or postop) PCSV23 (8wk later) PPSV23 (5yr later) PPSV23 (after age 65) History of TWO doses PPSV23 PCV13 (2wk preop or postop) PPSV23 (after age 65) 3

4 History of PPSV23 AND PCV13 (Age 19 64) History of ONE dose PPSV23 AND PCV13 PCSV23 (8wk later) PPSV23 (after age 65) No history of PCV13 Age 65 PCV13 (2wk preop or postop) PPSV23 (8 weeks later) History of TWO doses PPSV23 AND PCV13 History of of PCV13 PPSV23 (after age 65) PPSV23 (at least 5yr after previous PPSV23) N. meningitidis Meningitis, sepsis, pneumonia Low rates of invasive disease in US 1.2 million cases worldwide 10 15% fatal cases 20% of survivors with permanent damage Neurologic disability, amputation, hearing loss 40 70% mortality rate in Quadrivalent Meningococcal Vaccines Serogroups A, C, W and Y Single initial dose + booster MPSV4 (Menomune ) Polysaccharide SubQ only Adults >55 years Discontinued Lots expired 9/2017 MenACWY D (Menactra ) Adults 55 years Can NOT be administered with PCV13 MenACWY CRM (Menveo ) Adults 55 years Can be administered with PCV13 Pace D et al. Vaccine 2012; 30 (suppl 2):B3 9 CDC. MMWR Recomm Rep 2013; 62 (RR 2):1 28 CDC. MMWR Recomm Rep 2013; 62 (RR 2): announcements/menomune discontinuation Monovalent Meningococcal Vaccines Serogroup B Added to ACIP recommendations in 2015 MenB 4C Bexsero Two dose series Administer doses at least one month apart MenB FHbp Trumenba Three dose series Administer at 0, 1 2 and 6 months interval MCV4 + MenB Use MenACWY CRM if PCV13 2 weeks pre or post op Vaccination Schedule 8 weeks later MCV4 + MenB Use same products as first doses MenB FHpb: 0.5ml IM x1 MenB 4C: not 4 months later MCV4: quadrivalent meningococcal vaccine (Menactra, Meveo) MenB: serogroup B meningococcal vaccine (Trumenba, Bexsero) Every 5 years MCV4 booster Forlaranmi T et al. MMWR 2015;64: Forlaranmi T et al. MMWR 2015;64:

5 H. influenzae Type B Most common of the 6 serotypes 95% of invasive disease Meningitis, pneumonia, epiglottitis Low risk of invasive infection in adolescents and adults Hib Vaccine Monovalent conjugate ActHIB, Hiberix, Pedvax HIB Single dose, IM only Vaccinate Unvaccinated Vaccination status unknown Revaccination not Primary series by 6mo + booster Single dose after 14 mo Influenza Predisposition to secondary bacterial pneumonia and sepsis Unvaccinated vs minimum of one vaccination Retrospective study 54% decrease in risk of death in vaccinated group Annual immunization recommended Live attenuated vaccine not recommended Safety and efficacy data not available Improving Vaccination Rates Development of order sets Improve patient capture Providing patient education Stress importance of vaccines post splenectomy Involvement in transitions of care Improve communication between providers CDC. MMWR 2017; 66(2);1 20 Langley JM et al. BMC Infect Dis 2010; 10:219 Kealey, GP et al. J Surg Research 2015; 199:580 5 Summary Spleen destroys encapsulated organisms Lifetime risk of OPSI Recommended vaccines Pneumococcal, Meningococcal, Hib, Influenza Timing of initial vaccines At least 2 weeks pre or post op Opportunities to improve vaccination rates No Spleen? No Problem. A Review of Vaccinations Indicated for the Asplenic Patient SCSHP Fall Meeting October 26, 2017 Alyson G. Wilder, PharmD, BCPS Assistant Professor of Pharmacy Practice Presbyterian College School of Pharmacy 5

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