Recommendation Rules based on Age

• If a patient is < 5 years and has completed the Child series (including meeting the PCV 13 Rule), then the Recommendation is Not Recommended and the reason code is COMPLETE_HIGH_RISK.  
• If a patient is >= 5 years (or will be >= 5 years at the recommended due date) and < 19 years and they have completed the Child Series, then the Recommendation is Conditional and the reason code is COMPLETE_HIGH_RISK; otherwise the Recommendation is Conditional and the reason code is HIGH_RISK.
• If a patient is >= 5 years (or will be >= 5 years at the recommended due date) and < 19 years, and they have NOT completed the Child Series, then the Recommendation is Conditional and the reason code is HIGH_RISK.

Rules for Recommending at the CVX Code vs. Vaccine Group Level

• When recommending in the Child Series, always recommend at the CVX level; vaccine recommended should be PCV 13 (CVX 133).

• When recommending in the Adult Series,

  • If the patient is >= 19 years old, then always recommend at the CVX level:

    • If a PPSV (CVX 33, 109) dose was not administered at >= 65 years minus 4 days, then recommend PPSV 23 (CVX 33) at routine age of 65 years. 
    • If a PPSV (CVX 33, 109) dose was administered at >= 65 years minus 4 days, then the Adult series is complete. Recommend PPSV 23 (CVX 33) as Not Recommended and the reason code is COMPLETE.  
  • If the patient is >= 65 years old, and:
    • If a PCV (CVX 133, 152) shot was not administered, ICE will return recommendation reason code SUPPLEMENTAL_TEXT and Descriptive Text:"Consider PCV13 based on shared clinical decision making for adults 65 years or older. MMWR. 2019;68(46);1069–1075.", along with the vaccine group recommendation. (Implementation Note: this text is output via the output_supplemental_text option in ICE. If this feature is not enabled, the text is not output. See the ICE Implementation Guide for details.)
    • If a PCV (CVX 133, 152) shot was administered, ICE will NOT return any recommendation reason code SUPPLEMENTAL_TEXT and Descriptive Text, along with the vaccine group recommendation. 

Series Name

• Pneumococcal Child Series
• Pneumococcal Adult Series
  

Series Selection Rules

• The Child Series applies if the patient is < 5 years old; otherwise, the Adult series applies.
  

Series Special Rules 

Pneumococcal Child Series 4-dose Series Exception Rules

Follow the Pneumococcal Child 4-dose series tables (above) unless one of the following exceptions applies:

• Exception 1: If a child is >= 7 months and < 12 months at time of execution and
  • A. Has received 0 doses prior to 7 months then:
    
    • 3 doses are indicated (dose 2, 3, and 4) at >= 7 months.
    • Routine age is 7 months for target dose 2.
    • Recommended interval is 28 days between doses 2 and 3; recommended interval is 56 days between doses 3 and 4.
    • For dose 4, the absolute minimum age is 1 year - 4 days and the recommended age is 12 months (see table).
    • If target dose 4 is administered at < 1 year - 4 days the shot is Invalid and the reason code is BELOW_MINIMUM_AGE_FINAL_DOSE.
  • B. Has received 1 dose prior to 7 months then:
    
    • 2 additional doses are indicated (dose 3 and 4; dose 2 is skipped) at > = 7 months.
    • Routine age is 7 months for target dose 3.
    • Recommended interval is 28 days between doses 2 and 3; Recommended interval is 56 days between doses 3 and 4.
    • For dose 4, the absolute minimum age is 1 year - 4 days and the recommended age is 12 months (see table).
    • If target dose 4 is administered at < 1 year - 4 days the shot is Invalid and the reason code is BELOW_MINIMUM_AGE_FINAL_DOSE.

•  Exception 2: If a child is >= 12 months and < 24 months at time of execution and 
  
  • A. Has received < 2 doses administered at < 12 months of age then:
    
    • 2 doses are indicated (dose 3 and 4) at >= 12 months.
    • Routine age is 12 months for target dose 3.
    • Recommended interval is 28 days between doses 2 and 3; recommended interval is 56 days between doses 3 and 4.

    - Or -

  • B. Has received 2 doses administered at < 12 months of age then:
    
    • 1 dose is indicated (dose 4) at >= 12 months. 
    • Routine age is 12 months for target dose 4.
    • Recommended interval is 56 days between doses 3 and 4.

• Exception 3: If a child is >= 24 months and < 5 years at time of execution and has not completed their series prior to the age of 24 months then:
  • 1 dose is indicated (dose 4) at >= 24 months. 
  • Routine age is 24 months for target dose 4.
  • Recommended interval is 56 days between doses 3 and 4.

 PCV 13 Rule

• If a child is complete for the series, has not had a dose of PCV 13 (CVX 133), is currently < 5 years old, and will be < 5 years old at the recommended due date, then a dose of PCV 13 (CVX 133) is recommended. Recommended interval is 8 weeks and minimum interval is 52 days from the previous shot.
  

Maximum Age for Completing Child Series

• Shots administered to a patient >= 5 years of age do not count toward completion of the Child Series; the Child Series can NOT be completed once the patient is >= 5 years old.

Recommended Interval and Minimum Interval Exception Rules Based on PPSV23 and PCV (CVX  100, 133, 152, 109) Interaction

For patients < 2 years old:

• Recommended Interval: if a PPSV23 (CVX 33) shot has been given, the recommended interval is 0 days from the PPSV23 to the next target dose of PCV in the child series. For the purpose of recommendation, ignore the PPSV23 shot.
  
• Minimum Interval: the minimum interval between a PPSV23 (CVX33) shot and the target dose of PCV is 0 days. For the purpose of evaluation of the PCV, ignore the PPSV23 shot.

For patients >= 2 years old and < 5 years old:

• Recommended Interval: if a PPSV23 (CVX 33) shot has been given to a patient >= 2 years old and < 5 years old and the patient will be < 5 years old at the recommended due date, the recommended interval is 56 days from the PPSV23 to the next target dose of PCV in the child series. If the patient will be >= 5 years old and < 65 years at the recommended due date then the Recommendation is Conditional and the reason code is HIGH_RISK.
  
• Minimum Interval: the minimum interval between a PPSV23 (CVX33) shot and the target dose of PCV is 0 days. For the purpose of evaluation of the PCV, ignore the PPSV23 shot.¹

 Child Series Invalid CVX Code for Dose Rule

• If administered as a target dose in the Child Series, CVX codes listed as invalid per dose should be evaluated as Accepted with a reason code of VACCINE_NOT_PART_OF_THIS_SERIES. 

Notes

• While the CDC CDSi rules allow a 4-day grace period for the Pneumococcal skip dose trigger ages, the ICE Workgroup has decided not to allow grace periods for the Pneumococcal skip dose trigger ages. The ICE Workgroup has made this decision because:
  • Grace periods should not be permitted to reduce the total number of doses (e.g., in skip dose/catch-up schedules).
  • Catch-up schedules should not be made additionally lenient by including grace periods.
  • The ICE algorithm should steer providers toward the schedule that most closely approximates the routine schedule.
• Per Needle Tips, Vaccinate Adults - March 2015, IAC Express - Issue 1176: Question: Rather than giving PCV13 first and waiting 8 weeks to give PPSV23 as recommended for an immunocompromised child (2 years or older) or adult patient, we inadvertently gave both vaccines at the same visit. We are looking for guidance. Answer: Although PCV13 and PPSV23 should not be administered at the same visit, CDC does not recommend repeating either vaccine dose should this occur.¹ 

Series Special Rules

Rules for Shots Administered Below the Absolute Minimum Age for Dose 1 in the Adult Series

• PPSV (CVX 33 or 109)
  
  • If a patient's age at administration is >= 5 years of age and < 65 years - 4 days of age, then a PPSV shot (CVX 33 or 109) is evaluated as Accepted and the reason code is BELOW_REC_AGE_SERIES.
    • Minimum interval from the accepted PPSV to target dose in the adult series = 5 years
      • If PPSV is given below the minimum interval, then evaluation is Invalid and the reason is BELOW_MINIMUM_INTERVAL
    • Recommended interval from the accepted PPSV to target dose in the adult series = 5 years
     

Rules for PCV (CVX 133 or 152) Shots Administered >= 5 Years Old

• PCV (CVX 133 or 152)
  
  • If a patient's age at administration is >= 5 years of age and < 65 years of age, then a PCV shot (CVX 133 or 152) is evaluated as Accepted and the reason code is OUTSIDE_SERIES. (new reason code)
  • If a patient's age at administration is >= 65 years, then a PCV shot (CVX 133 or 152) is evaluated as Accepted and the reason code is CLINICAL_PATIENT_DISCRETION.

Recommended/Minimum/Absolute Minimum Intervals between PPSV and PCV 

• Interval from PCV (CVX 133 or 152) to PPSV (CVX 33 or 109):
  • Recommended interval = 1 year
  • Minimum interval = 1 year
  • Absolute minimum interval = 0 days
• Interval from PPSV (CVX 33 or 109) to PCV (CVX 133 or 152):
  • Recommended interval = N/A
  • Minimum interval - N/A
  • Absolute minimum interval - 0 days

Adult Series Invalid CVX Code for Dose Rules

• Rule for CVX 100 (PCV 7)

  • If CVX 100 (PCV 7) is reported, then evaluate as Accepted and the reason code is VACCINE_NOT_ALLOWED. Ignore the reported CVX 100 when determining the recommended vaccine and calculating the recommended due date for the next target dose.

• Rule for PCV (CVX 133 or 152)

  • Refer to the above "Rules for PCV (CVX 133 or 152) Shots Administered >= 5 Years Old"

Notes

• CDC CDSi rules apply a maximum (vaccine type end) age of 5 years and the test cases stop recommending PCV once a patient is >= 5 years. ICE continues to recommend PCV (conditionally) for high-risk patients who are >= 5 years.²