Series Name

• Pneumococcal Child Series

• Pneumococcal Adult PCV-PPSV Series

• Pneumococcal Adult PPSV-PCV Series

Series Selection Rules

• If the patient is < 5 years old, the Pneumococcal Child Series applies. 
• If the patient is >= 5 years old, either the Pneumococcal Adult PCV-PPSV Series or Pneumococcal Adult PPSV-PCV Series applies:
  
  • If PPSV23 (CVX 33) is administered for dose 1 at >= 19 years of age, the Pneumococcal Adult PPSV-PCV Series applies.
  • Otherwise, the Pneumococcal Adult PCV-PPSV Series applies.

 Recommendation Rules based on Age

• If a patient is < 5 years and has completed the Child series (including meeting the PCV13 / PCV15 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.
• 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.

Child Recommendation Rules

• When recommending in the Child Series, always recommend at the CVX level; vaccine recommended should be PCV13 (CVX 133).

Series Special Rules 

Pneumococcal Child Series 4-dose Series Exception Rules

If a PCV20 (CVX 216) is administered in the Pneumococcal Child Series, the absolute minimum age for the vaccine is 6 weeks - 4 days.

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.

  PCV13 / PCV15 / PCV 20 Rule

• If a child is complete for the series, has not had a dose of PCV13 (CVX 133), PCV15 (CVX 215) or PCV20 (CVX 216), is currently < 5 years old, and will be < 5 years old at the recommended due date, then a dose of PCV13 (CVX 133), PCV15 (CVX 215) or PCV20 (CVX 216) 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

• CDC CDSi rules and test cases evaluate CVX 100 (PCV 7) as invalid (i.e., not allowable) if given as target dose 4. The ICE Workgroup could not find any official guidance that suggests CVX 100 is not acceptable as dose 4, but rather found guidance that the series cannot be completed with PCV 7 only (once the PCV 13 vaccine became available). ICE allows PCV 7 for dose 4¹ but follows the PCV13 / PCV15 / PCV 20 Rule, when applicable, that recommends a dose of PCV 13. 
• 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 

Evaluation Rules for Shots Administered at >= 5 years and < 19 years

• If a PCV15 or PCV20 (CVX 215, CVX 216) is administered at >= 18 years - 4 days and < 19 years of age, evaluate the shot as VALID. 
  
• If a PCV15 or PCV20 (CVX 215, CVX 216) is administered at < 18 years - 4 days, evaluate the shot as INVALID / BELOW_MINIMUM_AGE_VACCINE.
• Otherwise, if a Pneumococcal vaccine is administered at >= 5 years and < 19 years of age, evaluate the shot as ACCEPTED / OUTSIDE_ROUTINE_SERIES.

Series Evaluation Rule for Pneumococcal Adult PCV-PPSV Series and Pneumococcal Adult PPSV-PCV Series

• If an administered shot >= 19 years of age is Invalid for the target dose in the series, and the series is not complete, evaluate the shot as ACCEPTED / OUTSIDE_ROUTINE_SERIES. Recommend the next shot based on intervals defined for the target dose in the series.
• If CVX 109 or CVX 152 is administered in an adult series, evaluate the shot as INVALID / VACCINE_NOT_ALLOWED_FOR_THIS_DOSE and SUPPLEMENTAL_TEXT with Descriptive Text: "CVX 109 and CVX 152 are unspecified vaccine formulations. Please update this record with the specific vaccine administered so that the shot can be evaluated accurately and the next dose in the series can be recommended."

Adult Recommendation Rules

• The Recommended Interval from a previously administered PPSV23 (CVX 33) or CVX 109 shot to the next target PPSV23 dose is 5 years.
• The Recommended Interval from a previously administered CVX 133, CVX 152, CVX 215, or CVX 216 shot to the next target dose is 1 year.
• If a (valid) PCV20 dose has been administered, the series is complete. (This general rule is also reflected in both series' special rules section.)
• If the patient is >= 19 years and < 65 years of age and the series is not complete, include reason code SUPPLEMENTAL_TEXT and Descriptive Text: "The Pneumococcal evaluations and recommendations in ICE primarily target the routine series. Adults ages 19-64 with underlying medical conditions or other risk factors who have not previously received PCV or whose previous vaccination history is unknown should receive 1 dose of PCV (either PCV20 or PCV15). When PCV15 is used, it should be followed by a dose of PPSV23 at the appropriate interval(s). Patients who previously received a PCV13 should receive PCV20 or PPSV23. Refer to ACIP for additional information."
• If the patient is < 65 years of age, has received a valid dose in an Adult Series at < 65 years old and the series is not complete, and the next recommended shot is >= 6 years from the execution date, recommend Conditional/ HIGH_RISK. 

Rule for PCV7 (CVX 100) Shots Administered >= 5 years Old

• PCV7 (CVX 100)
  • If CVX 100 (PCV7) 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.

Series Special Rules

Series Evaluation Special Rules

Follow the Pneumococcal Adult PCV-PPSV 3-dose series tables as defined above, unless one of the following exceptions applies:

• Target Dose 1:
  • If a Valid PCV20 (CVX 216) dose was previously administered before target dose 1 (i.e. - at >= 18 years - 4 days of age and < 19 years of age), the series is complete. No additional doses need to be administered.
  • If a Valid PCV15 (CVX 215) dose was previously administered before target dose 1 (i.e.  - at >= 6 weeks - 4 days of age and < 19 years of age), target dose 1 is not required. Skip to target dose 2.
  • If a Valid or Accepted PCV13 (CVX 133) or PCV15 (CVX 215) shot was previously administered before target dose 1, target dose 1 is not required. Skip to target dose 2.
  • If a Valid PCV20 (CVX 216) dose is administered for dose 1, the series is complete. No additional doses need to be administered.

• Target Dose 2
  • If a PCV20 (CVX 216) dose is administered for target dose 2, the series is complete. No additional doses need to be administered.
  • If dose 2 is administered and a prior Valid PCV15 (CVX 215) dose was previously administered, the series is complete. No additional doses need to be administered.
  • If dose 2 is administered at >= 65 years of age, the series is complete. No additional doses need to be administered.
• Target Dose 3:
  • If a Valid PPSV23 (CVX 33) was previously administered at >= 65 years of age, target dose 3 is not required. The series is complete.

Series Recommendation Special Rules

• When a dose is recommended for target dose 1, recommend at the vaccine group level with recommendation reason code is ADMINISTER_PCV15_OR_PCV20.  
• When a dose is recommended for target dose 2 or target dose 3, recommend at the vaccine level with CVX 33 (PPSV23) with recommendation reason code SUPPLEMENTAL_TEXT and Descriptive Text: "If PPSV23 is unavailable, PCV20 may be administered. No further doses of any type of pneumococcal vaccine are recommended after PCV20 is given."

Series Special Rules

Series Evaluation Special Rules

Follow the Pneumococcal Adult PPSV-PCV 3-dose series tables as defined above, unless one of the following exceptions applies:

• Target Dose 1
  • If a Valid PCV20 (CVX 216) dose was previously administered before target dose 1 (i.e.  - at >= 18 years - 4 days of age and < 19 years of age), the series is complete. No additional doses need to be administered.
  • If a Valid PCV20 (CVX 216) dose is administered for dose 1, the series is complete. No additional doses need to be administered.

• Target Dose 2:
  
  • If a Valid PCV15 (CVX 215) dose was previously administered before target dose 1 (i.e.  - at >= 6 weeks - 4 days of age and < 19 years of age), target dose 2 is not required. Skip to target dose 3.
  • If a Valid or Accepted PCV13 (CVX 133) or PCV15 (CVX 215) shot was previously administered before target dose 1, target dose 2 is not required. Skip to target dose 3.
  • If a Valid PCV15 or PCV20 (CVX 215, CVX 216) dose is administered for dose 2, the series is complete. No additional doses need to be administered.
  • If a PPSV23 (CVX 33) shot is administered for target dose 2 instead of PCV13, PCV15 or PCV20 (CVX 133, CVX 215 or CVX 216) and the patient is >= 65 years of age, evaluate the shot as Valid.
• Target Dose 3:
  • If a Valid PPSV23 (CVX 33) was previously administered at >= 65 years of age and a Valid or Accepted PCV13 or PCV15 (CVX 133 or CVX 215) was previously administered, target dose 3 is not required. The series is complete.

Series Recommendation Special Rules

• When a dose is recommended for target dose 2, recommend at the vaccine group level with recommendation reason code returned is ADMINISTER_PCV15_OR_PCV20.
• If PPSV23 (CVX 33) dose is administered for target dose 2 (atypical), recommend at the vaccine group level with recommendation reason code returned is ADMINISTER_PCV15_OR_PCV20. Otherwise, when a dose is recommended for target dose 1 or target dose 3, the recommended vaccine is CVX 33 (PPSV23) with recommendation reason code SUPPLEMENTAL_TEXT and Descriptive Text: "If PPSV23 is unavailable, PCV20 may be administered. No further doses of any type of pneumococcal vaccine are recommended after PCV20 is given."

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