1.  Condition for protocol: To reduce incidence of morbidity and mortality of Streptococcus pneumoniae disease.

2.  Policy of protocol: The nurse will implement this protocol for pneumococcal conjugate, 13-valent (PCV13) vaccination of at-risk persons.

3.  Condition-specific criteria and prescribed actions:

Instructions for persons adopting these protocols: The table below list indication, contraindication, and precaution criteria and suggested prescribed actions that are necessary to implement the vaccine protocol. The prescribed actions include examples shown in [ ] but may not suit your institution’s clinical situation and may not include all possible actions. A licensed prescriber must review the criteria and actions and determine the appropriate action to be prescribed. (Delete this paragraph before version is signed.)

Criteria

/

Prescribed Action

Indication

/ Person is currently healthy. / Give PCV13 if meets additional criteria.
Child less than age 2 years. / Follow Protocol for Infant Routine & Catch-up Pneumococcal Conjugate, 13-valent (PCV13) Vaccination.
Child age 2 to 6 years (through 71 months) with an underlying medical or immunocompromising condition and has never received a dose of PCV13.
·  Underlying medical conditions: chronic heart disease, chronic lung disease (including asthma requiring high-dose oral corticosteroids), diabetes, CSF fluid leaks & cochlear implant.
·  Immunocompromising conditions: sickle cell disease and hemoglobinopathies, congenital or acquired asplenia, or splenic dysfunction, HIV infection, chronic renal failure and nephritic syndrome, diseases requiring immunosuppressive treatment and congenital/acquired immunodeficiency. / Give PCV13 if no contraindications or precautions.
Immunocompetent child age 6 through 18 years that has an underlying medical condition including: chronic heart disease, chronic lung disease (including asthma requiring high-dose oral corticosteroids), and diabetes. / [Give PPSV23 using the Pneumococcal Polysaccharide Vaccine, 23-Valent (PPV23) Protocol for At-risk Persons Age 2 - 64 Years.]
[Refer to primary care provider.]
Person age 6 years or older that has not previously received PCV13 and has an immunocompromising condition including: anatomic or functional asplenia including sickle cell disease & other hemoglobinopathies; congenital or acquired immunodeficiencies; HIV infection; chronic renal failure; nephrotic syndrome; diseases requiring immunosuppressive treatment, including malignant neoplasms, leukemia, lymphomas, and Hodgkin disease; generalized malignancy; solid organ transplantation; or multiple myeloma; or one of these high risk conditions: CSF leak, cochlear implant. / Give PCV13 if no contraindications or precautions.

Contra-indication

/ Person had a systemic allergic reaction (e.g., anaphylaxis) to a previous dose of PCV13 vaccine. / Do not vaccinate; ______
Person has a systemic allergy (e.g., anaphylaxis) to a component of PCV13 vaccine. / Do not vaccinate; ______

Precaution

/ Person has received PPSV23 within the past 12 months. / ·  If person is 18 years or younger, defer vaccination until two months after PPSV23 was given;
·  If person is 19 years or older defer vaccination until 12 months after PPSV23 was given.
Person has a mild illness defined as temperature less than ____°F/°C with symptoms such as: {to be determined by medical prescriber} / Proceed to vaccinate.
Person has a moderate to severe illness defined as temperature of ____°F/°C or higher with symptoms such as: {to be determined by medical prescriber} / Defer vaccination and {to be determined by medical prescriber}

4.  Prescription:

Indication category / Prescription / Additional instruction
Age 2 through 71 months / PCV13 (Prevnar), 0.5 ml, IM, two doses 8 weeks apart. / Give PPSV23 eight or more weeks following PCV13 vaccination – see Pneumococcal Polysaccharide Vaccine, 23-Valent (PPV23) Protocol for At-risk Persons Age 2 - 64 Years.
Age 6 years and older / Give PCV13 (Prevnar) 0.5 ml, IM / Give PPSV23 eight or more weeks following PCV13 vaccination – see Pneumococcal Polysaccharide Vaccine, 23-Valent (PPV23) Protocol for At-risk Persons Age 2 - 64 Years.

5.  Medical emergency OR anaphylaxis: [Depending on clinic staffing, include one of the two options below.]

In the event of a medical emergency related to the administration of a vaccine. RN will apply protocols as described in ______.
In the event of an onset of symptoms of anaphylaxis including:
·  rash / ·  itchiness of throat / ·  swollen tongue or throat
·  difficulty breathing / ·  bodily collapse
LPN or unlicensed assistive personnel (MA) will immediately contact the RN in order to implement the
______.

6.  Questions or concerns:

In the event of questions or concerns, call Dr. ______at ______.

This protocol shall remain in effect for all patients of ______until rescinded or until ______.

Name of prescriber:

Signature:

Date:

Document reviewed & updated: ______– Sample protocol: PCV13 at risk 2-64 – MDH version: 06/2016 Page 2 of 2