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Pneumococcal vaccination for splenectomized patients with thalassemia major in Indonesia
Vaccine xxx (2017) xxx–xxx
Contents lists available at ScienceDirect
Vaccine journal homepage: www.elsevier.com/locate/vaccine
Pneumococcal vaccination for splenectomized patients with thalassemia major in Indonesia Teny Tjitra Sari a,⇑, Arwin Ali P. Akib a, Djajadiman Gatot a, Alida Roswita Harahap b, Saptawati Bardosono c, Sri Rezeki S. Hadinegoro a a b c
Department of Child Health, Faculty of Medicine, Universitas Indonesia/Dr. Cipto Mangunkusumo Hospital, Jakarta, Indonesia Department of Clinical Pathology, Faculty of Medicine, Universitas Indonesia/Dr. Cipto Mangunkusumo Hospital, Jakarta, Indonesia Department of Clinical Nutrition, Faculty of Medicine, Universitas Indonesia/Dr. Cipto Mangunkusumo Hospital, Jakarta, Indonesia
a r t i c l e
i n f o
Article history: Received 31 March 2017 Received in revised form 25 June 2017 Accepted 3 July 2017 Available online xxxx Keywords: Thalassemia Pneumococcal vaccination
a b s t r a c t Introduction: Streptococcus pneumoniae is a capsulated bacterium that can cause severe infection in patients with thalassemia major, particularly those who have undergone splenectomy. The absence of the spleen as well as zinc deficiency in splenectomized patients with thalassemia major increases the possibility of developing invasive pneumococcal infection. The aims of this study are to evaluate pneumococcal IgG levels following PCV and PPV immunizations and the effect of zinc supplementation on qualitative specific immune responses in splenectomized patients with thalassemia. Methods: Splenectomized patients with thalassemia major were administered a PCV pneumococcal vaccine (Prevenar 13Ò) at the start of the trial, after which they were randomly assigned to 2 groups (zinc and placebo group). After 8 weeks, the patients received a PPV pneumococcal vaccine (PneumovaxÒ). Zinc syrup was provided to the zinc group at a dose of 1.5 mg/kg/day (maximum of 50 mg/day). Pneumococcal IgG examinations were conducted at the start of the trial and after 12 weeks. Results: In the group without PPV, the median initial pneumococcal IgG value was 315 (ranging from 65 to 1419) mU/mL for the zinc group and 338.5 (ranging from 82 to 1648) mU/mL for the placebo group. The median final pneumococcal IgG value was 1812.5 (ranging from 834 to 2444) mU/mL for the zinc group and 2857.5 (ranging from 834 to 2624) for the placebo group. The increase in the pneumococcal IgG value between the two groups was comparable (p = 0.642). In the group with previous PPV, the median initial pneumococcal IgG value was 1333 (ranging from 793 to 2031) mU/mL for the zinc group and 880 (ranging from 74 to 1686) mU/mL for the placebo group. The median final pneumococcal IgG value was 1487 (ranging from 635 to 1757) mU/mL for the zinc group and 1012 (ranging from 292 to 1732) mU/mL for the placebo group. The increase in the pneumococcal IgG value between the two groups was comparable (p = 0.528). Conclusion: There is no difference in the increase in pneumococcal IgG level in splenectomized patients with thalassemia major prior to and after receiving PPV. There were no differences observed in the development of pneumococcal IgG following zinc supplementation. Ó 2017 Published by Elsevier Ltd.
1. Introduction Thalassemia is a hereditary anemia that occurs due to a monogenic disorder causing a defect in globin production [1]. The increased vulnerability of thalassemia patients to infection is attributed to their immune response, which is different from that of normal individuals [2–5]. Streptococcus pneumoniae is a capsulated bacterium that can cause severe infection in patients with thalassemia, particularly ⇑ Corresponding author.
those who have undergone splenectomy, and it may lead to a high mortality rate. The absence of the spleen as well as zinc deficiency in splenectomized patients with thalassemia major increases the possibility of developing invasive pneumococcal infection [6–8]. In splenectomized patients, the absence of the spleen leads to an inability to activate T cell-independent immune responses in the event of infections or immunization with a capsulated polysaccharide antigen such as S. pneumoniae [9]. The Thalassemia International Federation (TIF) and various countries recommend providing immunization against S. pneumoniae, H. influenza, and meningococcus at least 2 weeks prior to surgery, followed by
E-mail address: [email protected] (T.T. Sari). http://dx.doi.org/10.1016/j.vaccine.2017.07.011 0264-410X/Ó 2017 Published by Elsevier Ltd.
Please cite this article in press as: Sari TT et al. Pneumococcal vaccination for splenectomized patients with thalassemia major in Indonesia. Vaccine (2017), http://dx.doi.org/10.1016/j.vaccine.2017.07.011
2
T.T. Sari et al. / Vaccine xxx (2017) xxx–xxx
administration of prophylactic antibiotics to prevent infections following splenectomy [10–13]. In Indonesia, a majority of patients with thalassemia scheduled for splenectomy are not provided with immunization or prophylactic antibiotics because of financial limitations. Therefore, an effort to increase the immune response of patients with thalassemia is required, particularly following splenectomy. Several studies show that in when zinc deficiency is present, the process of antibody formation may be disturbed following administration of several vaccines [6,14,15]. Animal studies have attempted to show these disturbances in antibody production following administration of pneumococcal vaccines under zinc deficiency condition [6]. This study aims to evaluate pneumococcal IgG levels following PCV and PPV immunizations and the effect of zinc supplementation on qualitative specific immune responses in splenectomized patients with thalassemia.
2. Methods All splenectomized patients with thalassemia major were administered a PCV pneumococcal vaccine (Prevenar 13Ò) at the start of the trial. The patients were then randomly assigned into one of two groups (the zinc group and the placebo group). Zinc was provided in syrup form at a dose of 1.5 mg/kg/day, with a maximum of 50 mg/day. The placebo was also provided in syrup form, with similar shape and flavor. Both zinc and placebo syrup were prepared for 4 weeks of consumption. At the end of week 4, all subjects underwent complete physical and hematology examinations. In week 8, subjects who had not received a PPV vaccine were administered a PPV pneumococcal vaccine (PneumovaxÒ). Subjects were then discharged home with a 4-week supply of either placebo or zinc syrup, based upon their original group placement. At the end of Week 12, all the thalassemia subjects underwent a complete history taking, a physical examination, and supporting examinations including a peripheral blood examination; peripheral blood smear; and testing for levels of ferritin, transferrin saturation, serum zinc, and pneumococcal IgG. Following data collection, data analysis and interpretation were conducted. Analysis was conducted using the Statistical Package for the Social Sciences (SPSS) version 20.0. Changes in numerical immunologic parameters were analyzed using the independent samples t-test when the data followed normal distribution; the Mann-Whitney test was used if the data did not follow normal distribution. Pneumococcal IgG levels were measured using the Pneumococcus IgG Immunopotency level/E-DG-MZ-001/04-04 kit (ZenTech, Belgium) in the PRODIA Laboratory, Jakarta, with results expressed in milliunit per millilitres (mU/mL). In agreement with the instructions, serum was diluted to 1:510. Titers of anti-PCP IgG antibodies expressed as mU/mL were determined in accordance to the standard serum provided with the kit. Sensitivity of the kit was reported at 6.9 mU/mL. The results (based on the manufacturer) are interpreted as follows: hyporesponsive if <250 mU/mL, and good response or immune to pneumococcal infections if 250 mU/mL. This assay was already validated and used in studies conducted by Jahromi et al. [22] Evaluations of zinc levels were conducted using the Inductive Couple Plasma Mass Spectrometry (ICP/MS) method. Frequency of blood transfusions was classified using the Fucharoen classification [16]. This study was conducted following ethical approval by the Ethics Committee of the Faculty of Medicine, Universitas Indonesia, with ethical approval number 260/H2.F1/ETIK/2013.
3. Results This study included 56 samples with a median age of 21 years (range 12–38 years) and 56.8% female participants. Characteristic of samples used in this study are shown in Table 1. Most of the samples used had high ferritin levels (median range of 6950.31), with deferiprone as the most frequently used iron chelator. The presence of hepatitis infection in the patient can also be an important indicator of immune response. In this particular study, 12 patients were identified as having hepatitis B and 22 patients as having hepatitis C; information regarding the presence of cirrhosis was not gathered from the samples. In this study, 50 patients had not received pneumococcal immunization; hence they were given PCV and PPV immunizations. Six patients (4 from the zinc group and 2 from the placebo group) had previously received PPV immunization, and they were given only PCV immunization. The pneumococcal immunization provided by the hospital to the 6 patients who underwent splenectomy between 2009 and 2013 was the PPV vaccine; this was due to financial limitations of these patients, as PPV is less expensive than PCV. Majority of the study population (80.4%) possessed low zinc levels, with an average zinc level of 46.46 (±8.86). The effects of zinc supplementation on changes in pneumococcal IgG levels in patients who did not receive previous PPV immunization are presented in Table 2. Table 2 shows that at the start of the trial, immunity from pneumococcal IgG had already been attained (>250 mU/mL) in the group which did not receive PPV. Following immunization, pneumococcal IgG levels increased in both groups. Comparison between the zinc and placebo groups showed no significant differences in the increase in pneumococcal IgG following immunization. The median initial pneumococcal IgG level for the group who had previously received PPV immunization (6 patients) was 1333 (range 793 to 2031) mU/mL for the zinc group (n = 4) and 880 (range 74–1686) mU/mL for the placebo group. The median final pneumococcal IgG level was 1487 (range 635–1757) mU/mL for the zinc group and 1012 (range 292–1732) mU/mL for the placebo group. There was a comparable increase in pneumococcal IgG in the two groups (p = 0.528). All patients who had previously received a PPV immunization attained protective levels of pneumococcal IgG (>250 mU/mL); however, this generally decreased with an increase in the duration of pneumococcal antibody protection (Table 3).
Table 1 Characteristics of the study population. Parameters Type of thalassemia Beta Beta-HbE Nutritional status Good Undernourished Severely undernourished Frequency of blood transfusions Seldom (<1 time per year) Sometimes (2–3 times per year) Often ( 4 times per year) Type of blood transfusions PRC Leukodepleted PRC Washed PRC Ferritin (ng/mL) Transferrin saturation (%) Positive hepatitis markers Hepatitis B Hepatitis C
Number of Subjects (n = 56) 28 28 26 19 11 3 2 51 4 21 31 6950.31 (645–21,835) 94.84 (26–118) 12 22
Please cite this article in press as: Sari TT et al. Pneumococcal vaccination for splenectomized patients with thalassemia major in Indonesia. Vaccine (2017), http://dx.doi.org/10.1016/j.vaccine.2017.07.011
T.T. Sari et al. / Vaccine xxx (2017) xxx–xxx Table 2 Effects of zinc supplementation on pneumococcal IgG levels in patients who did not receive previous PPV immunization. Pneumococcal IgG Levels
Initial (mU/mL) Final (mU/mL) p-value2 Change (mU/mL) Percentage change
* 1 2
Zinc Group (n = 24)
Placebo Group (n = 26)
Median (Range) 315 (65–1419) 1,812.5 (834–2444) <0.001 Mean (SD) 1420.83 (377.32) Median (Range) 413.50 (72.23–1935.51)
Median (Range) 338.5 (82–1648) 1857.50 (652–2624) <0.001 Mean (SD) 1,353.0 (626.09) Median (Range) 406.58 ( 4.79 to 2261.86)
p-value
0.6761
0.642* 0.6001
Independent samples t-test. Mann-Whitney test. Wilcoxon signed-rank test.
Table 3 Pneumococcal IgG levels in the splenectomized subjects who had previously received PPV immunization. Patient number
Age at PPV immunization
Duration of pneumococcal antibody protection
Pneumococcal IgG level (mU/mL)
1 2 3 4 5 6
18 years 13 years 14 years 19 years 21 years 25 years
4 months 6 months 9 months 12 months 16 months 45 months
793 1686 2031 1859 807 74
The duration since splenectomy for the group that had not previously received PPV (50 patients) was 127.5 (53–243) months, whereas that value for the group that had previously received PPV (6 patients) was 17 (11–52) months (p < 0.001). There was no significant correlation between duration since splenectomy and changes in pneumococcal IgG levels (r = 0.222, p = 0.101).
4. Discussion In this study, patients who did not previously receive PPV immunization were provided with PCV immunization followed by PPV immunization after an interval of 6–8 weeks. On the other hand, patients who had previously received PPV immunization were provided only with PCV immunization, as it had been less than 5 years since their last PPV immunization, in accordance with the guidelines of the Indonesian Society of Pediatricians/Ikatan Dokter Anak Indonesia (IDAI) [17] and the Advisory Committee on Immunization Practices (ACIP) [18]. There were no significant differences in the increase in pneumococcal IgG levels between the patients who did not receive PPV and those who did as well as between the zinc and placebo groups. This study shows that there is no effect on the production of pneumococcal IgG following zinc supplementation, accounting for the fact that a majority of the subjects in this study population also had zinc deficiency. In agreement with previous studies [19,20] patients with thalassemia do not experience disturbances in their humoral immunity. The increase in pneumococcal IgG is higher in subjects who have not previously received PPV, as PCV plays a role in the development of memory B cells [21]. This can manifest as a high increase in the pneumococcal IgG level (>4-fold) following the administration of PPV. Subjects who have previously received PPV showed a relatively small increase in pneumococcal IgG levels, as pneumococcal IgG levels tend to decrease after the duration of
3
protection reaches 4 years; this indicates that the PPV vaccine produces only a small amount of memory due to short-term immunity and lack of booster response [19,22]. The administration of PCV will repair the production of memory B cells to maintain immunity against pneumococcus [19]. Only a small percentage of patients (6 out of 56) received PPV immunization prior to splenectomy, and a large majority of the patients had not previously received PPV immunization. Regardless of this, subjects who have not previously been immunized showed protective levels of pneumococcal IgG (>250 mU/mL), demonstrating possible previous exposure to pneumococcus antigen prior to the study. Because of the endemicity of pneumococcus in Indonesia, prior exposure to its antigen can be quite common, thus explaining why some of the samples had protective IgG levels without history of immunization. A 4-fold increase following pneumococcus immunization is considered an adequate antibody formation response, even without a spleen [23]. A study by Orthopoulos et al. [19] shows that the administration of PCV and PPV vaccines to splenectomized patients with thalassemia results in an immunological memory similar to that which results from the administration of 2 PCV vaccines with an interval of 1 month. This agrees with a study by Breukels et al. [24] which stated that the spleen does not greatly affect the anamnestic response process. In contrast to a previous study [20], this study did not find a correlation between duration since splenectomy and changes in pneumococcal IgG levels from baseline. A study by Jahromi et al. [20] measured pneumococcal IgG levels following PPV immunization prior to splenectomy, and found a strong negative correlation between protective pneumococcal IgG levels, and duration since splenectomy (r = 0.863, p = 0.0001). The study was unable to examine all the factors that may alter the final immune response; presence of hepatitis in some patients may be concomitant with presence of cirrhosis, which in turn may hinder immune response. Because of the limited availability of samples, the study was unable to examine immune response in relationship to gender or age. Age may play an important role, as older patients may have more mature immune systems. Studies with larger samples need to be conducted in the future to find significant results. In conclusion, splenectomized patients with administered with PCV 13 would have similar immunological responses compared to non-splenectomized patients, but further studies with healthy control groups are required to confirm the result. Zinc supplementation does not affect the production of pneumococcal IgG.
Conflict of interest This author declares no conflict of interest.
References [1] Rund D, Rachmilewitz E. b-thalassemia. N Engl J Med 2005;353:1135–46. [2] Wiener E. Impaired phagocyte antibacterial effector functions in bthalassemia: a likely factor in the increased susceptibility to bacterial infections. Hematology 2003;8:35–40. [3] Consolini R, Calleri A, Legitimo A, Massei F. Immunological evaluation of patients with beta-thalassemia major. Acta Haematol 2001;105:7–12. [4] Vento S, Cainelli F, Cesario F. Infections and thalassemia. Lancet Infect Dis 2006;6:226–33. [5] Ricerca BM, Di Girolamo A, Rund D. Infections in thalassemia and hemoglobinopathies: focus on therapy-related complications. Mediterr J Hematol Infect Dis 2009;1:e2009028. Downloaded on 15 February 2012 from http://www.mjhid.org/article/view/5229. [6] Strand TA, Hollingshead SK, Julshamn K, Briles DE, Blomberg B, Sommerfelt H. Effects of zinc deficiency and pneumococcal surface protein A immunization on zinc status and the risk of severe infection in mice. Infect Immun 2003;71 (4):2009–13.
Please cite this article in press as: Sari TT et al. Pneumococcal vaccination for splenectomized patients with thalassemia major in Indonesia. Vaccine (2017), http://dx.doi.org/10.1016/j.vaccine.2017.07.011
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[7] Jirillo E, Mastronardi ML, Altamura M, Munno I, Miniello S, Urgesi G, Amati L. The immunocompromised host: immune alterations in splenectomized patients and clinical implications. Curr Pharm Des 2003;9(24):1918–23. [8] Shafeeq S, Kuipers OP, Kloosterman TG. The role of zinc in the interplay between pathogenic streptococci and their hosts. Molecular microbiology. 2013;88(6):1047–57. [9] Sabatino AD, Carsetti R, Corazza GR. Post-splenectomy and hyposplenic states. Lancet. 2011;378:86–97. [10] Davies JM, Lewis MPN, Wimperis J, Rafi I, Ladhani S, Bolton-Maggs PHB. Review of guidelines for the prevention and treatment of infection in patients with an absent or dysfunctional spleen: prepared on behalf of the British Committee for Standars in Haematology by a Working Party of the HaematoOncology Task Force. Br J Haematol 2011;155:308–17. [11] Hasse B, Moll C, Oehy K, Röthlind M, Krause M. Anti-infectious prophylaxis after splenectomy: current practice in an eastern region of Switzerland. Swiss Med Wkly 2005;135:291–6. [12] Cappellini MD, Cohen A, Eleftheriou A, Piga A, Porter J, Taher A. Guidelines for the clinical management of thalassaemia. Edisi ke-2. Cyprus: Thalassaemia International Federation; 2008. p.106–20. [13] Del Vecchio GC, Schettini F, Piacente L, De Santis A, Giordano P, De Mattia DD. Effects of deferiprone on immune status and cytokine pattern in thalassemia major. Acta Haematol 2002;108:144–9. [14] Albert MJ, Qadri F, Wahed MA, Ahmed T, Rahman ASMH, Ahmed F, et al. Supplementation with zinc, but not vitamin A, improves seroconversion to vibriocidal antibody in children given an oral cholera vaccine. JID 2003;187:909–13. [15] Ibs KH, Rink L. Zinc-altered immune function. J Nutr 2003;133:S1452–6.
[16] Fucharoen S, Winichagoon P, Pootrakul P, Piankijagum A, Wasi P. Variable severity of Southeast Asian beta 0-thalassemia/Hb E disease. Birth Defects Orig Artic Ser 1987;23:241–8. [17] Baratawidjaja KG, Rengganis I. Imunologi dasar, 11th ed. Jakarta: Badan Penerbit Fakultas Kedokteran Universitas Indonesia; 2014. p. 41–745. [18] Mahyar A, Ayazi P, Pahlevan AA, Mojabi H, Sehhat MR, Javadi A. Zinc and copper status in children with beta-thalassemia major. Iran J Pediatr 2010;20:297–302. [19] Gibson RS, Hess SY, Hotz C, Brown KH. Indicators of zinc status at the population level: a review of literature. British J Nutr 2008;99:S14–23. [20] Tran CD, Miller LV, Krebs NF, Lei S, Hambidge KM. Zinc absorption as a function of the dose of zinc sulfate in aqueous solution. Am J Clin Nutr 2004;80:1570–3. [21] Orthopoulos GV, Theodoridou MC, Ladis VA, Tsousis DK, Spoulou VI. The effect of 23-valent pneumococcal polysaccharide vaccine on immunological priming induced by 7-valent conjugate vaccine in asplenic subjects with B-thalassemia. Vaccine 2009;27:350–4. [22] Jahromi AS, Farjam MR, Makarem A, Karami MY, Amanat A, Madani A. Immunity to pneumococcal vaccine in splenectomized b-thalassemia patients. Am J Immunol 2012;8:33–7. [23] Hare ND, Smith BJ, Ballas ZK. Antibody response to pneumococcal vaccination as a function of preimmunization titer. J Allergy Clin Immunol 2009;123 (1):195–200. [24] Breukels MA, Zandvoort A, van Den Dobbelsteen GP, van Den Muijsenberg A, Lodewijk ME. Beurret M, dkk. Pneumococcal conjugate vaccines overcome splenic dependency of antibody response to pneumococcal polysaccharides. Infect Immun 2001;69:7583–7.
Please cite this article in press as: Sari TT et al. Pneumococcal vaccination for splenectomized patients with thalassemia major in Indonesia. Vaccine (2017), http://dx.doi.org/10.1016/j.vaccine.2017.07.011
Contents lists available at ScienceDirect
Vaccine journal homepage: www.elsevier.com/locate/vaccine
Pneumococcal vaccination for splenectomized patients with thalassemia major in Indonesia Teny Tjitra Sari a,⇑, Arwin Ali P. Akib a, Djajadiman Gatot a, Alida Roswita Harahap b, Saptawati Bardosono c, Sri Rezeki S. Hadinegoro a a b c
Department of Child Health, Faculty of Medicine, Universitas Indonesia/Dr. Cipto Mangunkusumo Hospital, Jakarta, Indonesia Department of Clinical Pathology, Faculty of Medicine, Universitas Indonesia/Dr. Cipto Mangunkusumo Hospital, Jakarta, Indonesia Department of Clinical Nutrition, Faculty of Medicine, Universitas Indonesia/Dr. Cipto Mangunkusumo Hospital, Jakarta, Indonesia
a r t i c l e
i n f o
Article history: Received 31 March 2017 Received in revised form 25 June 2017 Accepted 3 July 2017 Available online xxxx Keywords: Thalassemia Pneumococcal vaccination
a b s t r a c t Introduction: Streptococcus pneumoniae is a capsulated bacterium that can cause severe infection in patients with thalassemia major, particularly those who have undergone splenectomy. The absence of the spleen as well as zinc deficiency in splenectomized patients with thalassemia major increases the possibility of developing invasive pneumococcal infection. The aims of this study are to evaluate pneumococcal IgG levels following PCV and PPV immunizations and the effect of zinc supplementation on qualitative specific immune responses in splenectomized patients with thalassemia. Methods: Splenectomized patients with thalassemia major were administered a PCV pneumococcal vaccine (Prevenar 13Ò) at the start of the trial, after which they were randomly assigned to 2 groups (zinc and placebo group). After 8 weeks, the patients received a PPV pneumococcal vaccine (PneumovaxÒ). Zinc syrup was provided to the zinc group at a dose of 1.5 mg/kg/day (maximum of 50 mg/day). Pneumococcal IgG examinations were conducted at the start of the trial and after 12 weeks. Results: In the group without PPV, the median initial pneumococcal IgG value was 315 (ranging from 65 to 1419) mU/mL for the zinc group and 338.5 (ranging from 82 to 1648) mU/mL for the placebo group. The median final pneumococcal IgG value was 1812.5 (ranging from 834 to 2444) mU/mL for the zinc group and 2857.5 (ranging from 834 to 2624) for the placebo group. The increase in the pneumococcal IgG value between the two groups was comparable (p = 0.642). In the group with previous PPV, the median initial pneumococcal IgG value was 1333 (ranging from 793 to 2031) mU/mL for the zinc group and 880 (ranging from 74 to 1686) mU/mL for the placebo group. The median final pneumococcal IgG value was 1487 (ranging from 635 to 1757) mU/mL for the zinc group and 1012 (ranging from 292 to 1732) mU/mL for the placebo group. The increase in the pneumococcal IgG value between the two groups was comparable (p = 0.528). Conclusion: There is no difference in the increase in pneumococcal IgG level in splenectomized patients with thalassemia major prior to and after receiving PPV. There were no differences observed in the development of pneumococcal IgG following zinc supplementation. Ó 2017 Published by Elsevier Ltd.
1. Introduction Thalassemia is a hereditary anemia that occurs due to a monogenic disorder causing a defect in globin production [1]. The increased vulnerability of thalassemia patients to infection is attributed to their immune response, which is different from that of normal individuals [2–5]. Streptococcus pneumoniae is a capsulated bacterium that can cause severe infection in patients with thalassemia, particularly ⇑ Corresponding author.
those who have undergone splenectomy, and it may lead to a high mortality rate. The absence of the spleen as well as zinc deficiency in splenectomized patients with thalassemia major increases the possibility of developing invasive pneumococcal infection [6–8]. In splenectomized patients, the absence of the spleen leads to an inability to activate T cell-independent immune responses in the event of infections or immunization with a capsulated polysaccharide antigen such as S. pneumoniae [9]. The Thalassemia International Federation (TIF) and various countries recommend providing immunization against S. pneumoniae, H. influenza, and meningococcus at least 2 weeks prior to surgery, followed by
E-mail address: [email protected] (T.T. Sari). http://dx.doi.org/10.1016/j.vaccine.2017.07.011 0264-410X/Ó 2017 Published by Elsevier Ltd.
Please cite this article in press as: Sari TT et al. Pneumococcal vaccination for splenectomized patients with thalassemia major in Indonesia. Vaccine (2017), http://dx.doi.org/10.1016/j.vaccine.2017.07.011
2
T.T. Sari et al. / Vaccine xxx (2017) xxx–xxx
administration of prophylactic antibiotics to prevent infections following splenectomy [10–13]. In Indonesia, a majority of patients with thalassemia scheduled for splenectomy are not provided with immunization or prophylactic antibiotics because of financial limitations. Therefore, an effort to increase the immune response of patients with thalassemia is required, particularly following splenectomy. Several studies show that in when zinc deficiency is present, the process of antibody formation may be disturbed following administration of several vaccines [6,14,15]. Animal studies have attempted to show these disturbances in antibody production following administration of pneumococcal vaccines under zinc deficiency condition [6]. This study aims to evaluate pneumococcal IgG levels following PCV and PPV immunizations and the effect of zinc supplementation on qualitative specific immune responses in splenectomized patients with thalassemia.
2. Methods All splenectomized patients with thalassemia major were administered a PCV pneumococcal vaccine (Prevenar 13Ò) at the start of the trial. The patients were then randomly assigned into one of two groups (the zinc group and the placebo group). Zinc was provided in syrup form at a dose of 1.5 mg/kg/day, with a maximum of 50 mg/day. The placebo was also provided in syrup form, with similar shape and flavor. Both zinc and placebo syrup were prepared for 4 weeks of consumption. At the end of week 4, all subjects underwent complete physical and hematology examinations. In week 8, subjects who had not received a PPV vaccine were administered a PPV pneumococcal vaccine (PneumovaxÒ). Subjects were then discharged home with a 4-week supply of either placebo or zinc syrup, based upon their original group placement. At the end of Week 12, all the thalassemia subjects underwent a complete history taking, a physical examination, and supporting examinations including a peripheral blood examination; peripheral blood smear; and testing for levels of ferritin, transferrin saturation, serum zinc, and pneumococcal IgG. Following data collection, data analysis and interpretation were conducted. Analysis was conducted using the Statistical Package for the Social Sciences (SPSS) version 20.0. Changes in numerical immunologic parameters were analyzed using the independent samples t-test when the data followed normal distribution; the Mann-Whitney test was used if the data did not follow normal distribution. Pneumococcal IgG levels were measured using the Pneumococcus IgG Immunopotency level/E-DG-MZ-001/04-04 kit (ZenTech, Belgium) in the PRODIA Laboratory, Jakarta, with results expressed in milliunit per millilitres (mU/mL). In agreement with the instructions, serum was diluted to 1:510. Titers of anti-PCP IgG antibodies expressed as mU/mL were determined in accordance to the standard serum provided with the kit. Sensitivity of the kit was reported at 6.9 mU/mL. The results (based on the manufacturer) are interpreted as follows: hyporesponsive if <250 mU/mL, and good response or immune to pneumococcal infections if 250 mU/mL. This assay was already validated and used in studies conducted by Jahromi et al. [22] Evaluations of zinc levels were conducted using the Inductive Couple Plasma Mass Spectrometry (ICP/MS) method. Frequency of blood transfusions was classified using the Fucharoen classification [16]. This study was conducted following ethical approval by the Ethics Committee of the Faculty of Medicine, Universitas Indonesia, with ethical approval number 260/H2.F1/ETIK/2013.
3. Results This study included 56 samples with a median age of 21 years (range 12–38 years) and 56.8% female participants. Characteristic of samples used in this study are shown in Table 1. Most of the samples used had high ferritin levels (median range of 6950.31), with deferiprone as the most frequently used iron chelator. The presence of hepatitis infection in the patient can also be an important indicator of immune response. In this particular study, 12 patients were identified as having hepatitis B and 22 patients as having hepatitis C; information regarding the presence of cirrhosis was not gathered from the samples. In this study, 50 patients had not received pneumococcal immunization; hence they were given PCV and PPV immunizations. Six patients (4 from the zinc group and 2 from the placebo group) had previously received PPV immunization, and they were given only PCV immunization. The pneumococcal immunization provided by the hospital to the 6 patients who underwent splenectomy between 2009 and 2013 was the PPV vaccine; this was due to financial limitations of these patients, as PPV is less expensive than PCV. Majority of the study population (80.4%) possessed low zinc levels, with an average zinc level of 46.46 (±8.86). The effects of zinc supplementation on changes in pneumococcal IgG levels in patients who did not receive previous PPV immunization are presented in Table 2. Table 2 shows that at the start of the trial, immunity from pneumococcal IgG had already been attained (>250 mU/mL) in the group which did not receive PPV. Following immunization, pneumococcal IgG levels increased in both groups. Comparison between the zinc and placebo groups showed no significant differences in the increase in pneumococcal IgG following immunization. The median initial pneumococcal IgG level for the group who had previously received PPV immunization (6 patients) was 1333 (range 793 to 2031) mU/mL for the zinc group (n = 4) and 880 (range 74–1686) mU/mL for the placebo group. The median final pneumococcal IgG level was 1487 (range 635–1757) mU/mL for the zinc group and 1012 (range 292–1732) mU/mL for the placebo group. There was a comparable increase in pneumococcal IgG in the two groups (p = 0.528). All patients who had previously received a PPV immunization attained protective levels of pneumococcal IgG (>250 mU/mL); however, this generally decreased with an increase in the duration of pneumococcal antibody protection (Table 3).
Table 1 Characteristics of the study population. Parameters Type of thalassemia Beta Beta-HbE Nutritional status Good Undernourished Severely undernourished Frequency of blood transfusions Seldom (<1 time per year) Sometimes (2–3 times per year) Often ( 4 times per year) Type of blood transfusions PRC Leukodepleted PRC Washed PRC Ferritin (ng/mL) Transferrin saturation (%) Positive hepatitis markers Hepatitis B Hepatitis C
Number of Subjects (n = 56) 28 28 26 19 11 3 2 51 4 21 31 6950.31 (645–21,835) 94.84 (26–118) 12 22
Please cite this article in press as: Sari TT et al. Pneumococcal vaccination for splenectomized patients with thalassemia major in Indonesia. Vaccine (2017), http://dx.doi.org/10.1016/j.vaccine.2017.07.011
T.T. Sari et al. / Vaccine xxx (2017) xxx–xxx Table 2 Effects of zinc supplementation on pneumococcal IgG levels in patients who did not receive previous PPV immunization. Pneumococcal IgG Levels
Initial (mU/mL) Final (mU/mL) p-value2 Change (mU/mL) Percentage change
* 1 2
Zinc Group (n = 24)
Placebo Group (n = 26)
Median (Range) 315 (65–1419) 1,812.5 (834–2444) <0.001 Mean (SD) 1420.83 (377.32) Median (Range) 413.50 (72.23–1935.51)
Median (Range) 338.5 (82–1648) 1857.50 (652–2624) <0.001 Mean (SD) 1,353.0 (626.09) Median (Range) 406.58 ( 4.79 to 2261.86)
p-value
0.6761
0.642* 0.6001
Independent samples t-test. Mann-Whitney test. Wilcoxon signed-rank test.
Table 3 Pneumococcal IgG levels in the splenectomized subjects who had previously received PPV immunization. Patient number
Age at PPV immunization
Duration of pneumococcal antibody protection
Pneumococcal IgG level (mU/mL)
1 2 3 4 5 6
18 years 13 years 14 years 19 years 21 years 25 years
4 months 6 months 9 months 12 months 16 months 45 months
793 1686 2031 1859 807 74
The duration since splenectomy for the group that had not previously received PPV (50 patients) was 127.5 (53–243) months, whereas that value for the group that had previously received PPV (6 patients) was 17 (11–52) months (p < 0.001). There was no significant correlation between duration since splenectomy and changes in pneumococcal IgG levels (r = 0.222, p = 0.101).
4. Discussion In this study, patients who did not previously receive PPV immunization were provided with PCV immunization followed by PPV immunization after an interval of 6–8 weeks. On the other hand, patients who had previously received PPV immunization were provided only with PCV immunization, as it had been less than 5 years since their last PPV immunization, in accordance with the guidelines of the Indonesian Society of Pediatricians/Ikatan Dokter Anak Indonesia (IDAI) [17] and the Advisory Committee on Immunization Practices (ACIP) [18]. There were no significant differences in the increase in pneumococcal IgG levels between the patients who did not receive PPV and those who did as well as between the zinc and placebo groups. This study shows that there is no effect on the production of pneumococcal IgG following zinc supplementation, accounting for the fact that a majority of the subjects in this study population also had zinc deficiency. In agreement with previous studies [19,20] patients with thalassemia do not experience disturbances in their humoral immunity. The increase in pneumococcal IgG is higher in subjects who have not previously received PPV, as PCV plays a role in the development of memory B cells [21]. This can manifest as a high increase in the pneumococcal IgG level (>4-fold) following the administration of PPV. Subjects who have previously received PPV showed a relatively small increase in pneumococcal IgG levels, as pneumococcal IgG levels tend to decrease after the duration of
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protection reaches 4 years; this indicates that the PPV vaccine produces only a small amount of memory due to short-term immunity and lack of booster response [19,22]. The administration of PCV will repair the production of memory B cells to maintain immunity against pneumococcus [19]. Only a small percentage of patients (6 out of 56) received PPV immunization prior to splenectomy, and a large majority of the patients had not previously received PPV immunization. Regardless of this, subjects who have not previously been immunized showed protective levels of pneumococcal IgG (>250 mU/mL), demonstrating possible previous exposure to pneumococcus antigen prior to the study. Because of the endemicity of pneumococcus in Indonesia, prior exposure to its antigen can be quite common, thus explaining why some of the samples had protective IgG levels without history of immunization. A 4-fold increase following pneumococcus immunization is considered an adequate antibody formation response, even without a spleen [23]. A study by Orthopoulos et al. [19] shows that the administration of PCV and PPV vaccines to splenectomized patients with thalassemia results in an immunological memory similar to that which results from the administration of 2 PCV vaccines with an interval of 1 month. This agrees with a study by Breukels et al. [24] which stated that the spleen does not greatly affect the anamnestic response process. In contrast to a previous study [20], this study did not find a correlation between duration since splenectomy and changes in pneumococcal IgG levels from baseline. A study by Jahromi et al. [20] measured pneumococcal IgG levels following PPV immunization prior to splenectomy, and found a strong negative correlation between protective pneumococcal IgG levels, and duration since splenectomy (r = 0.863, p = 0.0001). The study was unable to examine all the factors that may alter the final immune response; presence of hepatitis in some patients may be concomitant with presence of cirrhosis, which in turn may hinder immune response. Because of the limited availability of samples, the study was unable to examine immune response in relationship to gender or age. Age may play an important role, as older patients may have more mature immune systems. Studies with larger samples need to be conducted in the future to find significant results. In conclusion, splenectomized patients with administered with PCV 13 would have similar immunological responses compared to non-splenectomized patients, but further studies with healthy control groups are required to confirm the result. Zinc supplementation does not affect the production of pneumococcal IgG.
Conflict of interest This author declares no conflict of interest.
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Please cite this article in press as: Sari TT et al. Pneumococcal vaccination for splenectomized patients with thalassemia major in Indonesia. Vaccine (2017), http://dx.doi.org/10.1016/j.vaccine.2017.07.011