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Influenza and Pneumococcal Vaccination – Adult/Pediatric – Inpatient/Ambulatory

Influenza and Pneumococcal Vaccination – Adult/Pediatric – Inpatient/Ambulatory - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Clinical Practice Guidelines, Infection and Isolation


1
Influenza and Pneumococcal Vaccination –
Adult/Pediatric – Inpatient/Ambulatory/Primary
Care/Home Health –
Clinical Practice Guideline
Table of Contents
EXECUTIVE SUMMARY .............................................................................................................................. 3
SCOPE .......................................................................................................................................................... 4
METHODOLOGY .......................................................................................................................................... 4
INTRODUCTION ........................................................................................................................................... 5
RECOMMENDATIONS ................................................................................................................................. 5
UW HEALTH IMPLEMENTATION ............................................................................................................... 5
REFERENCES .............................................................................................................................................. 6
APPENDIX A. INFLUENZA VACCINATION SCREENING FOR IMMUNIZATION DELEGATION
PROTOCOL [60] .......................................................................................................................................... 8
APPENDIX B. INFLUENZA VACCINATION SCREENING (6 MONTHS-8 YEARS) ................................. 9
APPENDIX C. INFLUENZA VACCINE AND PEOPLE WITH EGG ALLERGIES .................................... 10
APPENDIX D. PNEUMOCOCCAL VACCINATION EXCLUSION CRITERIA FOR IMMUNIZATION
DELEGATION PROTOCOL [60] ................................................................................................................ 11
APPENDIX E. PNEUMOCOCCAL VACCINATION SCREENING (24-71 MONTHS) .............................. 12
APPENDIX F. PNEUMOCOCCAL VACCINATION SCREENING (2-18 YEARS WITH UNDERLYING
MEDICAL CONDITIONS) ........................................................................................................................... 13
APPENDIX G. PNEUMOCOCCAL VACCINATION SCREENING (6-18 YEARS) ................................... 14
APPENDIX H. PNEUMOCOCCAL VACCINATION SCREENING (>19 YEARS) .................................... 15
APPENDIX I. RECOMMENDED INTERVALS FOR SEQUENTIAL USE OF PCV-13 AND PPSV-23 FOR
IMMUNOCOMPETENT ADULTS AGED ≥65 YEARS ............................................................................... 16
APPENDIX J. MEDICAL CONDITIONS OR OTHER INDICATIONS FOR ADMINISTRATION OF PCV-
13 AND PPSV-23 FOR ADULTS ............................................................................................................... 17
CPG Contact for Changes & Content
Name: Philip Trapksin, PharmD, BCPS – Drug Policy Program
Phone Number: 608-263-1328
Email Address: ptrapskin@uwhealth.org
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2

Guideline Authors:
Center for Disease Control (CDC) Advisory Committee on Immunization Practices (ACIP)

Coordinating Team Members:
Joshua Vanderloo, PharmD, BCPS – Drug Policy Program

Review Individuals/Bodies:
James Conway, MD
Immunization Programming and Planning Committee
Antimicrobial Use Subcommittee

Committee Approvals/Dates:
Pharmacy and Therapeutics Committee: September 2017

Release Date: September 2017

Next Review Date: August 2018

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3

Executive Summary
Guideline Overview
UW Health has agreed to endorse the following CDC ACIP influenza and pneumococcal vaccination
recommendations:
• Prevention and Control of Seasonal Influenza with Vaccines: Recommendations of the Advisory
Committee on Immunization Practices — United States, 2017–18 Influenza Season
1

• Use of 13-Valent Pneumococcal Conjugate Vaccine and 23-Valent Pneumococcal
Polysaccharide Vaccine Among Adults Aged ≥65 Years: Recommendations of the Advisory
Committee on Immunization Practices (ACIP)
2

• Use of 13-Valent Pneumococcal Conjugate Vaccine and 23-Valent Pneumococcal
Polysaccharide Vaccine Among Children Aged 6–18 Years with Immunocompromising
Conditions: Recommendations of the Advisory Committee on Immunization Practices (ACIP)
3

• Use of 13-Valent Pneumococcal Conjugate Vaccine and 23-Valent Pneumococcal
Polysaccharide Vaccine for Adults with Immunocompromising Conditions: Recommendations of
the Advisory Committee on Immunization Practices (ACIP)
4

• Prevention of Pneumococcal Disease Among Infants and Children – Use of 13-Valent
Pneumococcal Conjugate Vaccine and 23-Valent Pneumococcal Polysaccharide Vaccine:
Recommendations of the Advisory Committee on Immunization Practices (ACIP)
5

• Updated Recommendations for Prevention of Invasive Pneumococcal Disease Among Adults
Using the 23-Valent Pneumococcal Polysaccharide Vaccine (PPSV23)
6

• Intervals Between PCV-13 and PPSV-23 Vaccines: Recommendations of the Advisory
Committee on Immunization Practices (ACIP)
7


Key Revisions (2017 Periodic Review)
1. Influenza vaccination recommendations updated to ACIP 2017-2018 recommendations.

Key Revisions (2017 Interim Revision)
1. Exclusion of patients with new diagnosis or history of GBS or AIDP.

Key Revisions (2016 Periodic Review)
1. ACIP recommends that live-attenuated influenza vaccine (LAIV, Flumist
®
) should not be used for
the 2016-17 influenza season due to evidence of poor efficacy to influenza A (H1N1) during the
2013-14 and 2015-16 influenza seasons.
8

2. ACIP updated recommendation for the management of patients with reported egg allergy.
3. The clinical criterion of residence in a long-term care facility or nursing home is no longer an
indication for pneumococcal vaccine.

Key Practice Recommendations
1. Screening and selection of influenza vaccine for patients older than six months of age and older
a. Influenza vaccine selection and schedule for patients aged 6 months to 8 years
b. Influenza vaccine selection and schedule for patients aged 9 years and older
2. Screening and selection of pneumococcal vaccine for patients six months of age and older.
a. Exclusion criteria for pneumococcal vaccination
b. Pneumococcal vaccine selection and schedule by indication for patients aged 6-18 years
with immunocompromising conditions
c. Pneumococcal vaccine selection and schedule by indication for patients aged 19 years
and older with immunocompromising conditions
d. Pneumococcal vaccine selection and schedule for patients 65 years and older.

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4

Companion Documents
• UW Health Immunization Toolkit

Scope
Diseases/Conditions:
• Influenza vaccination
• Pneumococcal vaccination

Clinical Specialty:
Pharmacy, Primary Care, Hospitalists, Family Medicine

Intended Users:
Pharmacists, Physicians, Advanced Practice Providers, Nurses, Medical Assistants

Objective:
To provide evidence-based guidelines for use of influenza and pneumococcal vaccines to prevent
respective infections.

Target Population
All patients six months of age and older.

Target Population:
All patients older than six months of age for influenza vaccine and all patients older than six months of
age for pneumococcal vaccine.

Major Outcomes Considered:
Appropriate vaccination with appropriate influenza and pneumococcal vaccines.

Methodology
Methods Used to Collect/Select the Evidence and Formulate the
Recommendations:
The Advisory Committee on Immunization Practice (ACIP) of the Centers for Disease Control (CDC)
develops recommendations for use of vaccines to control disease in the United States. ACIP provides
recommendations for the use of both influenza and pneumococcal vaccinations.

Methods Used to Assess the Quality and Strength of the Evidence:
Review of the literature and weighing according to the rating scheme as described below.

Rating Scheme for the Strength of the Evidence and Recommendations:
A modified Grading of Recommendations, Assessment, Development, and Evaluation (GRADE)
developed by ACIP was use to assess the quality and strength of the evidence and recommendations.
9


ACIP recommendation categories:
• Category A: Recommendation that applies to all persons in age- or risk-based group. Suggested
wordings include recommend, recommend against, should, and should not.
• Category B: Recommendation for individual clinical decision making. Suggested wordings
include may, and suggest against.
• No recommendation/unresolved issue.

ACIP body of evidence categorization:
1. Randomized controlled trials (RCTs), or overwhelming evidence from observational studies.
2. Randomized controlled trials with important limitations, or exceptionally strong evidence from
observational studies.
3. Observational studies or randomized controlled trials with notable limitations.
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5

4. Clinical experience and observations, observational studies with important limitations, or
randomized controlled trials with several major limitations.

Recognition of Potential Health Care Disparities:
The CDC Health Disparities and Inequalities Report provides information on identified healthcare
disparities and action plans for eliminating or minimizing these disparities, including immunizations.
10


Introduction
Influenza is an acute respiratory infection with both serious respiratory and non-respiratory
complications.
11
Pneumococcal disease is caused by Streptococcus pneumoniae and most often
presents as pneumonia in adults and may lead to invasive pneumococcal disease.
12
Vaccines for both
influenza and S. pneumoniae are effective in preventing disease.
13-16


Recommendations
Recommendations related to influenza and pneumococcal vaccination can be found at the ACIP
Recommendations webpage or by navigation to individual documents:
• Prevention and Control of Seasonal Influenza with Vaccines: Recommendations of the Advisory
Committee on Immunization Practices — United States, 2017–18 Influenza Season
1

• Use of 13-Valent Pneumococcal Conjugate Vaccine and 23-Valent Pneumococcal
Polysaccharide Vaccine Among Adults Aged ≥65 Years: Recommendations of the Advisory
Committee on Immunization Practices (ACIP)
2

• Use of 13-Valent Pneumococcal Conjugate Vaccine and 23-Valent Pneumococcal
Polysaccharide Vaccine Among Children Aged 6–18 Years with Immunocompromising
Conditions: Recommendations of the Advisory Committee on Immunization Practices (ACIP)
3

• Use of 13-Valent Pneumococcal Conjugate Vaccine and 23-Valent Pneumococcal
Polysaccharide Vaccine for Adults with Immunocompromising Conditions: Recommendations of
the Advisory Committee on Immunization Practices (ACIP)
4

• Prevention of Pneumococcal Disease Among Infants and Children – Use of 13-Valent
Pneumococcal Conjugate Vaccine and 23-Valent Pneumococcal Polysaccharide Vaccine:
Recommendations of the Advisory Committee on Immunization Practices (ACIP)
5

• Updated Recommendations for Prevention of Invasive Pneumococcal Disease Among Adults
Using the 23-Valent Pneumococcal Polysaccharide Vaccine (PPSV23)
6

• Intervals Between PCV-13 and PPSV-23 Vaccines: Recommendations of the Advisory
Committee on Immunization Practices (ACIP)
7

• ACIP Recommendations for Pneumococcal Vaccine Timing for Adults

UW Health Implementation
Potential Benefits:
• Prevention of pneumococcal and influenza disease and potential morbidity/mortality associated
with these infections
• Prevention of readmission

Potential Harms:
• Pain at injection site
• Potential adverse effects from immunization

Pertinent UW Health Policies and Procedures
1. UWMF Policy 102.079: Immunization Administration
2. UWHC Administrative Policy 8.20: Adverse Drug Event Documentation
3. UW Health Clinical Policy 3.1.1: Ambulatory Childhood Vaccine Refusal

Patient Resources
• CDC Vaccine Information Sheets
• Inactivated/recombinant Influenza Vaccine Information Sheet
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission.
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2018CCKM@uwhealth.org

6

• Inactivated/recombinant Influenza Vaccine Information Sheet in other languages
• Pneumococcal Polysaccharide (PPSV23) Vaccine Information Sheet
• Pneumococcal Conjugate (PCV13) Vaccine Information Sheet

Guideline Metrics:
1. Proportion of eligible patients receiving influenza or pneumococcal vaccines at discharge.
2. Proportion of eligible ambulatory patients who are up to date with influenza and pneumococcal
vaccines.

Implementation Plan/Tools
1. Guideline will be posted on UConnect in a dedicated location for Clinical Practice Guidelines.
2. Release of the guideline will be advertised in the Physician/APP Briefing newsletter.
3. Content and hyperlinks within clinical tools, documents, or Health Link related to the guideline
recommendations (such as the following) will be reviewed for consistency and modified as
appropriate.

Delegation Protocols
Immunization Delegation Protocol – Adult/Pediatric – Inpatient [60]
Immunization Delegation Protocol – Adult/Pediatric – Ambulatory [56]
Primary Care ‐ Laboratory Screening and Chronic Disease Monitoring Laboratory Test Ordering ‐
Adult/Pediatric ‐ Ambulatory [93]

Disclaimer
CPGs are described to assist clinicians by providing a framework for the evaluation and treatment of
patients. This Clinical Practice Guideline outlines the preferred approach for most patients. It is not
intended to replace a clinician’s judgment or to establish a protocol for all patients. It is understood that
some patients will not fit the clinical condition contemplated by a guideline and that a guideline will rarely
establish the only appropriate approach to a problem.

References
1. Grohskopf LA, Sokolow LZ, Broder KR, et al. Prevention and Control of Seasonal Influenza with Vaccines:
Recommendations of the Advisory Committee on Immunization Practices — United States, 2017–18
Influenza Season. MMWR. Recommendations and reports : Morbidity and mortality weekly report.
Recommendations and reports / Centers for Disease Control. 2017;66(No. RR-2):1-20.
2. Tomczyk S, Bennett NM, Stoecker C, et al. Use of 13-valent pneumococcal conjugate vaccine and 23-valent
pneumococcal polysaccharide vaccine among adults aged >/=65 years: recommendations of the Advisory
Committee on Immunization Practices (ACIP). MMWR. Morbidity and mortality weekly report. Sep 19
2014;63(37):822-825.
3. Use of 13-valent pneumococcal conjugate vaccine and 23-valent pneumococcal polysaccharide vaccine
among children aged 6-18 years with immunocompromising conditions: recommendations of the Advisory
Committee on Immunization Practices (ACIP). MMWR. Morbidity and mortality weekly report. Jun 28
2013;62(25):521-524.
4. Use of 13-valent pneumococcal conjugate vaccine and 23-valent pneumococcal polysaccharide vaccine for
adults with immunocompromising conditions: recommendations of the Advisory Committee on Immunization
Practices (ACIP). MMWR. Morbidity and mortality weekly report. Oct 12 2012;61(40):816-819.
5. Nuorti JP, Whitney CG. Prevention of pneumococcal disease among infants and children - use of 13-valent
pneumococcal conjugate vaccine and 23-valent pneumococcal polysaccharide vaccine - recommendations
of the Advisory Committee on Immunization Practices (ACIP). MMWR. Recommendations and reports :
Morbidity and mortality weekly report. Recommendations and reports / Centers for Disease Control. Dec 10
2010;59(Rr-11):1-18.
6. Updated recommendations for prevention of invasive pneumococcal disease among adults using the 23-
valent pneumococcal polysaccharide vaccine (PPSV23). MMWR. Morbidity and mortality weekly report. Sep
3 2010;59(34):1102-1106.
7. Kobayashi M, Bennett NM, Gierke R, et al. Intervals Between PCV13 and PPSV23 Vaccines:
Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR. Morbidity and
mortality weekly report. 2015;64(34):944-947.
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7

8. Grohskopf LA, Sokolow LZ, Broder KR, et al. Prevention and Control of Seasonal Influenza with Vaccines.
MMWR. Recommendations and reports : Morbidity and mortality weekly report. Recommendations and
reports / Centers for Disease Control. 2016;65(5):1-54.
9. Ahmed F, Temte JL, Campos-Outcalt D, Schunemann HJ. Methods for developing evidence-based
recommendations by the Advisory Committee on Immunization Practices (ACIP) of the U.S. Centers for
Disease Control and Prevention (CDC). Vaccine. Nov 15 2011;29(49):9171-9176.
10. Meyer PA, Yoon PW, Kaufmann RB. Introduction: CDC Health Disparities and Inequalities Report - United
States, 2013. MMWR Suppl. Nov 22 2013;62(3):3-5.
11. Wiselka M. Influenza: diagnosis, management, and prophylaxis. BMJ (Clinical research ed.). May 21
1994;308(6940):1341-1345.
12. Fedson DS, Liss C. Precise answers to the wrong question: prospective clinical trials and the meta-analyses
of pneumococcal vaccine in elderly and high-risk adults. Vaccine. Feb 25 2004;22(8):927-946.
13. Jefferson T, Di Pietrantonj C, Al-Ansary LA, Ferroni E, Thorning S, Thomas RE. Vaccines for preventing
influenza in the elderly. The Cochrane database of systematic reviews. 2010(2):Cd004876.
14. Jefferson T, Rivetti A, Di Pietrantonj C, Demicheli V, Ferroni E. Vaccines for preventing influenza in healthy
children. The Cochrane database of systematic reviews. 2012;8:Cd004879.
15. Jefferson TO, Rivetti D, Di Pietrantonj C, Rivetti A, Demicheli V. Vaccines for preventing influenza in healthy
adults. The Cochrane database of systematic reviews. 2007(2):Cd001269.
16. Moberley S, Holden J, Tatham DP, Andrews RM. Vaccines for preventing pneumococcal infection in adults.
The Cochrane database of systematic reviews. 2013;1:Cd000422.

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Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2018CCKM@uwhealth.org

8


Influenza and Pneumococcal Vaccination –
Adult/Pediatric – Inpatient/Ambulatory/Primary Care/Home Health – Clinical
Practice Guideline

Appendix A. Influenza Vaccination Screening for Immunization Delegation
Protocol [60]

Inclusion Criteria
• 6 months of age or older

Exclusion Criteria
• is aged 9 years or older has already received one dose of influenza vaccine during the
current influenza season
• caregiver or patient offered and declined the influenza vaccination
• has a hypersensitivity to eggs* of other components of the vaccine
• is hospitalized with an episode of acute inflammatory demyelinating polyneuropathy
(AIDP) or Guillain-Barré Syndrome (GBS) or has a history of AIDP or GBS (Neurologist
should determine when patient may again be eligible for vaccination)
• has a history of anaphylactic latex allergy
• is having a solid organ transplant (e.g. heart, lung, pancreas, kidney, liver, intestine)
during the current hospitalization
• has undergone a solid organ transplant (e.g. heart, lung, pancreas, kidney, liver,
intestine) in the past 6 months
• is having a bone marrow/stem cell transplant during the current hospitalization
• has undergone a bone marrow/stem cell transplant in the past 6 months
• is receiving palliative care
• has planned discharge to hospice care
• is enrolled in research protocol(s)

Additional exclusion criteria for patients aged 6 months to 8 years
• has received at least two doses of influenza vaccine during the current influenza season
• has received two or more doses of seasonal vaccine before July 1, 2017 and has
already received one dose of influenza vaccine during the current influenza season
• has received an influenza vaccine dose within the last 4 weeks

* Reported egg allergy excludes patients from the inpatient pharmacist-driven immunization
delegation protocol, but should not preclude patients from receiving influenza vaccine. Patients
with reported egg allergy should be evaluated by a physician for influenza vaccine screening.
See Appendix C.
Last approved by the UW P&T Committee, 9/2017
For content changes or questions contact Philip Trapskin ptrapskin@uwhealth.org

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9


Influenza and Pneumococcal Vaccination – Adult/Pediatric –
Inpatient/Ambulatory/Primary Care/Home Health –
Clinical Practice Guideline

Appendix B. Influenza Vaccination Screening (6 months-8 years)

Influenza vaccine dosing algorithm for children aged 6 months through 8 years —
Advisory Committee on Immunization Practices, United States, 2017–18 influenza season





Last approved by the UW P&T Committee, 9/2017
For content changes or questions contact Philip Trapskin ptrapskin@uwhealth.org

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Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2018CCKM@uwhealth.org

10


Influenza and Pneumococcal Vaccination –
Adult/Pediatric – Inpatient/Ambulatory/Primary Care/Home Health – Clinical
Practice Guideline

Appendix C. Influenza Vaccine and People with Egg Allergies

Recommendations regarding influenza vaccination of persons who report allergy
to eggs: Advisory Committee on Immunization Practices, United States, 2017-18
Influenza Season

• Persons with a history of egg allergy who have experienced only urticaria (hives) after
exposure to egg should receive influenza vaccine. Any licensed and recommended
influenza vaccine (i.e., any IIV or RIV) that is otherwise appropriate for the recipient’s
age and health status may be used.
• Persons who report having had reactions to egg involving symptoms other than urticaria
(hives), such as angioedema, respiratory distress, lightheadedness, or recurrent emesis;
or who required epinephrine or another emergency medical intervention, may similarly
receive any licensed and recommended influenza vaccine (i.e., any IIV or RIV) that is
otherwise appropriate for the recipient’s age and health status. The selected vaccine
should be administered in an inpatient or outpatient medical setting (including, but not
necessarily limited to, hospitals, clinics, health departments, and physician offices).
Vaccine administration should be supervised by a health care provider who is able to
recognize and manage severe allergic conditions.
• A previous severe allergic reaction to influenza vaccine, regardless of the component
suspected of being responsible for the reaction, is a contraindication to future receipt of
the vaccine.
Last approved by the UW P&T Committee, 9/2017
For content changes or questions contact Philip Trapskin ptrapskin@uwhealth.org

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Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2018CCKM@uwhealth.org

11

Influenza and Pneumococcal Vaccination – Adult/Pediatric –
Inpatient/Ambulatory/Primary Care/Home Health – Clinical
Practice Guideline
Appendix D. Pneumococcal Vaccination Exclusion Criteria for Immunization
Delegation Protocol [60]

Exclusion criteria for all patients
• caregiver or patient offered and declined pneumococcal vaccination
• hypersensitivity to component(s) of the vaccine
• pregnant
• is hospitalized with an episode of acute inflammatory demyelinating polyneuropathy
(AIDP) or Guillain-Barré Syndrome (GBS) or has a history of AIDP or GBS (Neurologist
should determine when patient may again be eligible for vaccination)
• enrolled in a research protocol
• 19 years or older and received PCV13 or PPSV23 in the previous 12 months; patient
should follow-up for additional pneumococcal screening to be evaluated by primary care
provider
• 19 years or older and previously received pneumococcal vaccine but unable to confirm
PCV13 or PPSV23; patient should follow-up with primary care provider following
discharge
• younger than 19 years of age and received PCV13 or PPSV23 in the previous 8 weeks
• has undergone a solid organ transplant (e.g. heart, lung, pancreas, kidney, liver,
intestine) in the past 6 months
• has undergone a bone marrow/stem cell transplant in the past 12 months
• has received chemotherapy or radiation in the last 2 weeks
• has received the shingles vaccine (Zostavax) within the past 4 weeks

Additional exclusion criteria for inpatients:
• planned discharge to hospice care
• having a solid organ transplant (e.g. heart, lung, pancreas, kidney, liver, intestine) during
the current hospitalization
• is having a bone marrow/stem cell transplant during the current hospitalization
• is receiving comfort measures only

Last approved by the UW P&T Committee, 9/2017
For content changes or questions contact Philip Trapskin ptrapskin@uwhealth.org

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Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2018CCKM@uwhealth.org

12

Influenza and Pneumococcal Vaccination – Adult/Pediatric –
Inpatient/Ambulatory/Primary Care/Home Health – Clinical Practice Guideline

Appendix E. Pneumococcal Vaccination Screening (24-71 months)

Table 1. Recommended schedule for administering doses of 13-valent pneumococcal conjugate vaccine (PCV13) to
children aged 24-71 months by PCV vaccination history and age
Age at this visit (months)
Vaccination history: total number of
PCV7 and/or PCV13 doses received
previously before age 24 months
Recommended PCV13 regimen
(Minimum interval between doses is 8
weeks)
24-59 months in healthy children
Unvaccinated or any incomplete
schedule
1 dose, ≥ 8 weeks after the most recent
dose
4 doses of PCV7 or other age-
appropriate, complete PCV7 schedule
1 supplemental dose, ≥8 weeks after the
most recent dose
24-71 months in children with
underlying medical conditions (see
Table 2 and Appendix F)

Unvaccinated or any incomplete
schedule of <3 doses
2 doses, the first dose ≥8 weeks after the
most recent dose and a second dose ≥ 8
weeks later
Any incomplete schedule of 3 doses
1 dose, ≥ 8 weeks after the most recent
dose
4 doses of PCV7 or other age-
appropriate complete PCV7 schedule
1 supplemental dose, ≥8 weeks after the
most recent dose
PCV7 = 7-valent pneumococcal polysaccharide-protein conjugate vaccine.


Table 2. Underlying medical conditions that are indications for pneumococcal vaccination among children by risk group
Risk group Condition
Immunocompetent children
Chronic heart disease
A
Chronic lung disease
B
Diabetes mellitus
Cerebrospinal fluid leaks
Cochlear implant
Children with functional or
anatomic asplenia
Sickle cell disease and other hemoglobinopathies
Congenital or acquired asplenia, or splenic dysfunction
Children with
immunocompromising
conditions
HIV infection
Chronic renal failure and nephrotic syndrome
Diseases associated with treatment with immunosuppressive drugs or radiation therapy,
including malignant neoplasms, leukemias, lymphomas and Hodgkin disease; or solid organ
transplantation
Congenital immunodeficiency
C

A
Particularly cyanotic congenital heart disease and cardiac failure
B
Including asthma if treated with high-dose oral corticosteroid therapy
C
Includes B- (humoral) or T-lymphocyte deficiency; complement deficiencies, particularly C1, C2, C3, and C4
deficiency; and phagocytic disorders (excluding chronic granulomatous disease).
Last approved by the UW P&T Committee, 9/2017
For content changes or questions contact Philip Trapskin ptrapskin@uwhealth.org






Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission.
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2018CCKM@uwhealth.org

13

Influenza and Pneumococcal Vaccination – Adult/Pediatric –
Inpatient/Ambulatory/Primary Care/Home Health – Clinical Practice Guideline

Appendix F. Pneumococcal Vaccination Screening (2-18 years with underlying medical
conditions)

Table 1. Schedule for vaccination using 23-valent polysaccharide vaccine (PPSV23) after 13-valent pneumococcal
conjugate vaccine (PCV13) for children aged ≥2 years with underlying medical conditions
Group Schedule for PPSV23 Revaccination with PPSV23
Children who are
immunocompromised, have sickle
cell disease, or functional or
anatomic asplenia
A
1 dose of PPSV23 administered at
age ≥2 yrs and ≥8 weeks after last
indicated dose of PCV13
B
1 dose 5 years after the first dose of
PPSV23
B
Immunocompetent children with
chronic illness
A
1 dose of PPSV23 administered at
age ≥2 yrs and ≥8 weeks after last
indicated dose of PCV13
B
Not recommended
B
A
See Table 2 below
B
See Appendix F

Table 2. Underlying medical conditions that are indications for pneumococcal vaccination among children by risk group
Risk group Condition
Immunocompetent children
Chronic heart disease
A
Chronic lung disease
B
Diabetes mellitus
Cerebrospinal fluid leaks
Cochlear implant
Children with functional or
anatomic asplenia
Sickle cell disease and other hemoglobinopathies
Congenital or acquired asplenia, or splenic dysfunction
Children with
immunocompromising
conditions
HIV infection
Chronic renal failure and nephrotic syndrome
Diseases associated with treatment with immunosuppressive drugs or radiation therapy,
including malignant neoplasms, leukemias, lymphomas and Hodgkin disease; or solid organ
transplantation
Congenital immunodeficiency
C

A
Particularly cyanotic congenital heart disease and cardiac failure
B
Including asthma if treated with high-dose oral corticosteroid therapy
C
Includes B- (humoral) or T-lymphocyte deficiency; complement deficiencies, particularly C1, C2, C3, and C4
deficiency; and phagocytic disorders (excluding chronic granulomatous disease).
Last approved by the UW P&T Committee, 9/2017
For content changes or questions contact Philip Trapskin ptrapskin@uwhealth.org






Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission.
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2018CCKM@uwhealth.org

14

Influenza and Pneumococcal Vaccination – Adult/Pediatric –
Inpatient/Ambulatory/Primary Care/Home Health – Clinical Practice Guideline

Appendix G. Pneumococcal Vaccination Screening (6-18 years)
Risk group
Underlying medical
condition
PCV13 PPSV23
Recommended Recommended
Revaccination
5 years after first
dose
Immunocompetent persons
Chronic heart disease
A


X

Chronic lung disease
B

X

Diabetes mellitus

X

Cerebrospinal fluid leaks X X

Cochlear implants X X

Alcoholism

X

Chronic liver disease

X

Cigarette smoking

X

Persons with functional or anatomic
asplenia
Sickle cell disease/other
hemaglobinopathies
X X X
Congenital or acquired
asplenia
X X X
Immunocompromised persons
Congenital or acquired
immunodeficiencies
C

X X X
Human immunodeficiency
virus infection
X X X
Chronic renal failure X X X
Nephrotic syndrome X X X
Leukemia X X X
Lymphoma X X X
Hodgkin disease X X X
Generalized malignancy X X X
Iatrogenic
immunosuppression
D
X X X
Solid organ transplant X X X
Multiple myeloma X X X
A
Including congestive heart failure and cardiomyopathies.
B
Including chronic obstructive pulmonary disease, emphysema, and asthma.
C
Includes B-(humoral) or T-lymphocyte deficiency, complement deficiencies (particularly C1, C2, C3, and C4
deficiencies), and phagocytic disorders (excluding chronic granulomatous disease)
D
Diseases requiring treatment with immunosuppressive drugs, including long-term systemic corticosteroids and
radiation therapy

Last approved by the UW P&T Committee, 9/2017
For content changes or questions contact Philip Trapskin ptrapskin@uwhealth.org

Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission.
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2018CCKM@uwhealth.org

15

Influenza and Pneumococcal Vaccination – Adult/Pediatric –
Inpatient/Ambulatory/Primary Care/Home Health – Clinical Practice Guideline

Appendix H. Pneumococcal Vaccination Screening (>19 years)
Risk group Underlying medical condition
PCV13 PPSV23
Recommended Recommended
Revaccination
5-yrs after first
dose
65 years of age or older X X
Immunocompetent
persons
Chronic heart disease
A

X

Chronic lung disease
B


X

Diabetes mellitus

X

Cerebrospinal fluid leaks X X

Cochlear implants X X

Alcoholism

X

Chronic liver disease

X

Cigarette smoking

X

Persons with functional
or anatomic asplenia
Sickle cell disease/other
hemaglobinopathies
X X X
Congenital or acquired asplenia X X X
Immunocompromised
persons
Congenital or acquired
immunodeficiencies
C
X X X
Human immunodeficiency virus infection X X X
Chronic renal failure X X X
Nephrotic syndrome X X X
Leukemia X X X
Lymphoma X X X
Hodgkin disease X X X
Generalized malignancy X X X
Iatrogenic immunosuppression
D
X X X
Solid organ transplant X X X
Multiple myeloma X X X
A
Including congestive heart failure and cardiomyopathies.
B
Including chronic obstructive pulmonary disease, emphysema, and asthma.
C
Includes B-(humoral) or T-lymphocyte deficiency, complement deficiencies (particularly C1, C2, C3, and C4
deficiencies), and phagocytic disorders (excluding chronic granulomatous disease)
D
Diseases requiring treatment with immunosuppressive drugs, including long-term systemic corticosteroids and
radiation therapy
Last approved by the UW P&T Committee, 9/2017
For content changes or questions contact Philip Trapskin ptrapskin@uwhealth.org

Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission.
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2018CCKM@uwhealth.org

16

Influenza and Pneumococcal Vaccination – Adult/Pediatric –
Inpatient/Ambulatory/Primary Care/Home Health –Clinical Practice Guideline

Appendix I. Recommended Intervals for sequential use of PCV-13 and PPSV-23
for Immunocompetent adults aged ≥65 years
A,B



A
In pneumococcal-naïve patients, administer PCV-13 first
B
For adults aged ≥65 years with immunocompromising conditions, functional or anatomic asplenia,
cerebrospinal fluid leaks, or cochlear implants, the recommended interval between PCV13 followed by
PPSV23 is ≥8 weeks. For those for who previously received PPSV23 when aged <65 years and for
whom an additional dose of PPSV23 is indicated when aged ≥65 years, this subsequent PPSV23 dose
should be given ≥1 year after PCV13 and ≥5 years after the most recent dose of PPSV23.



Last approved by the UW P&T Committee, 9/2017
For content changes or questions contact Philip Trapskin ptrapskin@uwhealth.org

Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission.
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2018CCKM@uwhealth.org

17

Influenza and Pneumococcal Vaccination – Adult/Pediatric –Inpatient/Ambulatory/Primary Care/Home Health –
Clinical Practice Guideline
Appendix J. Medical conditions or other indications for administration of PCV-13 and PPSV-23 for adults

Last approved by the UW P&T Committee, 9/2017
For content changes or questions contact Philip Trapskin ptrapskin@uwhealth.org

Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission.
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2018CCKM@uwhealth.org