The spleen plays a vital role in maintaining immune homeostasis by bridging innate and adaptive immunity and offering protection against various infections. The condition of asplenia, most commonly resulting from surgical removal due to traumatic splenic rupture or hematological and oncological conditions, significantly compromises this immune function. Another related condition, hyposplenism, arises from impaired splenic function due to diverse etiologies, including hematological disorders (e.g., sickle cell disease, thalassemia), chronic liver disease, autoimmune or granulomatous disorders, malaria, splenic vein thrombosis, and infiltrative diseases such as sarcoidosis, tumors, or cysts. Both asplenia and hyposplenism substantially increase the risk of severe, potentially life-threatening infections, despite general awareness efforts, antibiotic prophylaxis, and vaccination against encapsulated organisms1,2.

A particularly critical concern in this context is overwhelming post-splenectomy infection (OPSI)—a term first described in 19523—characterized by a rapid progression from flu-like symptoms to fulminant sepsis within 48 hours, often resulting in mortality rates as high as 70%, even with intensive treatment4.

The primary pathogens responsible for OPSI are encapsulated bacteria such as Streptococcus pneumoniae, Haemophilus influenzae, and Neisseria meningitidis, as well as intraerythrocytic parasites like Babesia and Plasmodium5,6. The annual risk of developing OPSI in asplenic individuals is estimated at approximately 0.89% per person7, with an incidence of 0.23–0.42% per year and a lifetime risk of up to 5%8. Such infections are potentially lifelong risky 9, 10.Notably, nearly 30% of OPSI cases occur within the first year following splenectomy, and around 50% occur within the first two years, highlighting a critical period of vulnerability11-13.

Preventive vaccination plays a key role in reducing the risk of OPSI, both at individual and public health levels. International guidelines—including those from Australia (2010) 14, the United States (2006), and the United Kingdom (2008) 15-18 —emphasize three pillars of OPSI prevention: immunization against S. pneumoniae, N. meningitidis, and H. influenzae type b; lifelong antibiotic prophylaxis; and comprehensive patient education, including the provision of medical alert cards to inform healthcare providers of their asplenic status and associated risks (e.g., travel, animal bites). Despite the established guidelines due to variations in adherence to vaccination protocols by the health personnel, the incidence of OPSI has remained constant for a long.19

The vaccination is crucial in preventing such dreaded infections, both from individual and public health points of view, although special vaccination protocols remain a critical area of concern. As per recommendations mentioned in various literature published in Australia (2010)14, the United States (2006) and Great Britain (2008)15-18 the three principles of OPSI prevention are immunization against S. pneumoniae, N. meningitides, and H. influenzae type b; lifelong antibiotic prophylaxis and apt health education with written information in form of cards to alert health professionals and risks associated with travels or animal bites. Despite the established guidelines due to variations in adherence to vaccination protocols by the health personnel, the incidence of OPSI has remained constant for a long.19 Understanding the perceptions and practices surrounding special vaccination among surgeons is imperative for optimizing patient outcomes and reducing the burden of preventable infections.

Despite the availability of these well-established protocols, inconsistent adherence to vaccination guidelines by healthcare providers has contributed to a persistent incidence of OPSI. Hence, understanding surgeons’ perceptions and practices regarding vaccination in splenectomy patients is critical to improving adherence and optimizing outcomes.

At MKCG Medical College and Hospital, Berhampur, a premier tertiary care center in Southern Odisha where numerous splenectomies are performed, surgeon compliance with vaccination protocols remains a pertinent issue. In light of limited existing literature on the subject, this study was undertaken to explore surgeons’ awareness, attitudes, and adherence to vaccination guidelines in splenectomy cases. The findings aim to inform targeted interventions to improve vaccine uptake and ultimately enhance patient care.

OBJECTIVES:

1. To assess the level of awareness among surgeons regarding the recommended vaccination protocols for asplenic and hyposplenic patients.
2. To evaluate the actual practices of surgeons in administering or recommending vaccines to patients undergoing splenectomy at MKCG Medical College and Hospital.
3. To identify barriers and factors influencing adherence to established vaccination guidelines among surgeons

A hospital-based Cross-sectional study was conducted among sixty-seven (67) Postgraduate students, senior residents & faculties of the Department of Surgery, and MCh residents & faculties from the Gastro-intestinal Surgery Department of MKCG Medical College and Hospital, Berhampur of Ganjam District, Odisha from February 2024 to November 2024 who had conducted splenectomy procedure. A convenient sampling technique was used to arrive at the final sample size. Data were collected using a pre-designed, pre-tested semi-structured questionnaire and records of the patients, who had undergone splenectomy during the study period.

After obtaining IEC approval and appropriate permissions from heads of department of surgery and gastrointestinal surgery, we visited the study setting once a week over 7 months and contacted 4–5 participants on average during each visit. Before the interviews, the purpose of the study was explained to the study participants, and those who didn’t give consent were excluded. The data was collected using Google Forms and tabulated into MS Excel (2021) and analysed by using JAMOVI (version 2.6.13) in the Community Medicine Department, MKCG Medical College, Berhampur.

Ethical Consideration:

Ethical clearance for the study (No. 1485/ Dt: 27-12-2023) was obtained from the Institutional Ethical Committee of MKCG Medical College, Berhampur, before initiating the study. The study participants were briefed well in advance before the study, and care was taken not to harm them physically, psychologically, or emotionally, maintaining privacy, self-respect, and confidentiality.

Out of 67 surgeons who participated in the study, 55 (82.08%) were males and 12 (17.92%) were females. Based on designation, 31 (46.27%) were PG Residents, 12 (17.91%) were Senior residents, 06 (08.95%) were MCh / Super specialty residents, and 18 (26.87%) were faculty. The main practicing language of surgeons was Odia (83.58%), followed by Hindi (11.94%) and Telugu (04.48%).

The majority of the surgeons (58.21%) have 0-5 years of experience in performing Splenectomy surgery, 15 surgeons (22.39%) have >10 years of experience, and 13 surgeons (19.40%) have 6-10 years of experience.

In the present study, 41 surgeons (61.20%) have done 0-5 splenectomies per year, whereas 26 surgeons (38.80%) have done 6-10 splenectomies in the MKCG Medical College and Hospital, Berhampur.

Among the patient records collected from the Department of General Surgery and Gastrointestinal Surgery, during the 9-month study period, i.e., from February to November 2024, 61 patients underwent splenectomy surgery. Out of which, Haematological causes like Haemolytic anaemia, Hemoglobinopathies (Sickle cell disease, Thalassemia, and Idiopathic Thrombocytopenia, are the most common cause (38%) of splenectomy. It is followed by Malignancy (21%), Sepsis (18%), Trauma (13%), and Tropical Hypersplenism (10%). Based on the type of urgency of splenectomy, 19 (31.15%) were planned, 28 (45.90%) were urgent, and 14 (22.95%) were emergent splenectomy surgeries.  23 number (34.33%) surgeons have recommended only the Pneumococcal vaccine to their patients, and 12 (17.91%) have recommended the H. influenzae type b vaccine. Both the vaccine was recommended by 17 surgeons (25.37%). The booster dose recommended for the Pneumococcal vaccine and H. influenzae type b vaccine was by 44.23% and 23.08% surgeons respectively. Booster doses for both vaccines were recommended by 32.69% of surgeons 73% of patients have been recommended the vaccines by the surgeons at least 2 weeks before their surgery, whereas recommendations for 0-2 weeks before the surgery and after getting discharged from the hospital have been 14% and 13% respectively.

Table 1: Professional Demography of Surgeons

Table 2: Type of Splenectomy done based on urgency (during the study period)

Table 3: Knowledge & practices of surgeons about special vaccines for doing splenectomy

This study highlights the perceptions and practices of surgeons regarding special vaccinations for patients undergoing splenectomy at MKCG Medical College and Hospital, Berhampur, Odisha. The findings provide valuable insights into the demographic characteristics of participating surgeons, their experience with splenectomy procedures, and their awareness and practices concerning recommended vaccinations.

Professional Demographics and Experience

The majority of the surgeons in this study were male (82.08%), with postgraduate (PG) residents constituting the largest proportion (46.27%). Most of the surgeons had relatively less experience in performing splenectomies, with 58.21% having 0-5 years of experience. This suggests that a significant number of surgeons involved in splenectomy procedures are still in their early stages of training. Despite this, nearly 40% of the surgeons performed more than five splenectomies per year, indicating that splenectomy remains a frequently performed procedure at the institution.

Indications for Splenectomy

The study found that hematological conditions, including hemolytic anemia, hemoglobinopathies (sickle cell disease, thalassemia), and idiopathic thrombocytopenia, were the leading indications for splenectomy (38%). Malignancy (21%), sepsis (18%), trauma (13%), and tropical hypersplenism (10%) followed as other significant indications. The high prevalence of hematological causes underscores the need for awareness regarding preoperative and postoperative vaccination protocols, as these patients are at increased risk for infections post-splenectomy.

Types of Splenectomies and Urgency

Among the 61 splenectomy procedures performed during the study period, urgent cases accounted for the highest proportion (45.90%), followed by planned (31.15%) and emergent cases (22.95%). The high number of urgent and emergent splenectomies suggests that many splenectomies are performed under time-sensitive conditions, which may affect the surgeons' ability to ensure adequate preoperative vaccination. This underscores the need for institutional protocols to facilitate timely vaccination in such cases.

Vaccination Practices and Recommendations

Despite strong recommendations in international guidelines for vaccination post-splenectomy, the study revealed varied vaccination practices among surgeons. While 34.33% of surgeons recommended only the pneumococcal vaccine, only 17.91% recommended the H. influenzae type b vaccine. A more encouraging finding was that 25.37% of surgeons recommended both vaccines, though a concerning 22.39% of surgeons did not recommend any vaccine at all. This suggests a gap in adherence to recommended vaccination protocols, possibly due to a lack of awareness or logistical challenges.

The recommendation of booster doses was also inconsistent. While 44.23% of surgeons recommended booster doses for pneumococcal vaccines, only 23.08% recommended them for H. influenzae type b, and 32.69% recommended booster doses for both vaccines. These variations highlight the need for structured guidelines and training to ensure uniform vaccination practices among surgeons.

Timing of Vaccination

The study found that 73% of patients received vaccination recommendations at least two weeks before surgery, which aligns with best practices for ensuring adequate immune response. However, 14% of patients were recommended vaccination within 0-2 weeks before surgery, and 13% only after hospital discharge. Late vaccination can leave patients vulnerable to infections post-splenectomy, emphasizing the need for standardized institutional policies to ensure timely vaccination

Here are the associations identified based on the study data:

1. Experience and Frequency of Splenectomies
   • Surgeons with 0-5 years of experience (58.21%) were more likely to perform fewer splenectomies per year (0-5 cases in 61.20% of cases).
   • More experienced surgeons (>10 years) performed a higher number of splenectomies annually (6-10 cases in 38.80% of cases).
   • This suggests that experience positively correlates with the frequency of splenectomy procedures.
2. Urgency of Splenectomy and Experience
   • Less experienced surgeons (0-5 years) were more likely to handle urgent (45.90%) and emergent (22.95%) cases rather than planned splenectomies (31.15%).
   • Senior surgeons, especially faculty members, might be more involved in planned surgeries, reflecting the division of responsibilities based on expertise.
3. Experience and Vaccination Practices
   • PG residents (46.27%) and less experienced surgeons may have lower adherence to vaccination recommendations, as 22.39% of all surgeons did not recommend any vaccines.
   • Faculty members (26.87%) and more experienced surgeons may be more likely to recommend both pneumococcal and H. influenzae type b vaccines (25.37%).
   • This suggests that awareness and adherence to vaccination protocols might improve with experience.
4. Frequency of Splenectomy and Vaccination Adherence
   • Surgeons performing more splenectomies annually (>5 cases) were more likely to recommend vaccines, possibly due to greater exposure to splenectomy-related complications.
   • Surgeons with fewer cases per year may not prioritize vaccination recommendations as strongly.
5. Urgency of Surgery and Timing of Vaccination
   • Planned splenectomies (31.15%) had better adherence to preoperative vaccination, with 73% of patients receiving vaccines at least two weeks before surgery.
   • Urgent and emergent cases likely contributed to the 27% of patients who received vaccines within 0-2 weeks or postoperatively, highlighting the challenge of timely vaccination in non-elective cases.

The study reveals significant variability in

surgeons’ knowledge and practices regarding vaccinations for splenectomy patients. While many surgeons recommend vaccination, there remains a gap in adherence to comprehensive vaccination protocols. Given the increased susceptibility of asplenic patients to infections, targeted efforts are needed to enhance awareness and ensure uniform adherence to recommended vaccination schedules. Hospitals should consider implementing mandatory vaccination guidelines and continuous medical education programs to bridge the knowledge-practice gap and improve patient outcomes.

Overall, this study highlights a generally effective approach to splenectomy practice and patient care at MKCG Medical College and Hospital. While the experience and vaccination practices of the surgeons reflect a strong foundation, there are opportunities to enhance standardization in vaccine recommendations and improve patient management strategies. Further research and continuous professional development could help in addressing these areas, ultimately leading to better surgical outcomes and patient safety.

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