Dr. Luis J. Lugo Velez

1. VACCINATION STANDARDS
IN ADULTS AND PEDIATRICS
IMMUNIZATION SCHEDULE 2019
LUIS J. LUGO VÉLEZ M.D. J.D. LL.M. FCLM
ASSISTANT PROFESSOR
PONCE HEALTH SCIENCES UNIVERSITY SCHOOL OF MEDICINE
ADJUNCT PROFESSOR
PONTIFICAL CATHOLIC UNIVERSITY SCHOOL OF LAW

2. The Advisory Committee on Immunization Practices (ACIP)
• The Advisory Committee on Immunization Practices (ACIP) comprises medical and public
health experts who develop recommendations on the use of vaccines in the civilian
population of the United States. The recommendations stand as public health guidance for
safe use of vaccines and related biological products.
• The Advisory Committee on Immunization Practices was established under Section 222 of
the Public Health Service Act (42 U.S.C. §2l7a), as amended.
• The committee is governed by the provisions of the Federal Advisory Committee Act, as
amended, 5 U.S.C. App., which sets forth standards for the formation and use of advisory
committees.

3. ACIP Meeting Information
• The ACIP holds three meetings each year at the Centers for Disease Control
and Prevention (CDC) in Atlanta, Georgia to review scientific data and vote
on vaccine recommendations. Meetings are open to the public and available
online via live webcast.

4. Recommended Immunization Schedule for Children and Adolescents Aged 18
Years or Younger,
UNITED STATES, 2019
• Table 1. Recommended Immunization Schedule for Children and Adolescents Aged 18
Years or Younger—United States, 2019
• Table 2. Catch-up immunization schedule for persons aged 4 months–18 years who start
late or who are more than 1 month behind. —United States, 2019
• Table 3. Recommended Child and Adolescent Immunization Schedule by Medical Indication
United States, 2019
• Notes — Recommended Immunization Schedule for Children and Adolescents Aged 18
Years or Younger, UNITED STATES, 2019

5. Recommended Immunization Schedule for Children and Adolescents Aged 18
Years or Younger,
UNITED STATES, 2019
• The Recommended Immunization Schedule for Children and Adolescents
Aged 18 Years or Younger are approved by the:
• Advisory Committee on Immunization Practices
• American Academy of Pediatrics
• American Academy of Family Physicians
• American College of Obstetricians and Gynecologists

7. Number of Diseases Prevented by Vaccines Included in the Routine
Child/Adolescent Immunization Schedule

8. Comparison of 20th Century Annual Morbidity and
Current Morbidity: Vaccine-Preventable Diseases
† JAMA. 2007;298(18):2155-2163
. MMWR January 6, 2017/ 64(52);ND-924 – ND-941. (MMWR 2016 week 52 provisional data)
* Haemophilus influenzae type b (Hib) < 5 years of age. An additional 11 cases of Hib are estimated to have occurred
among the 222 reports of Hib (< 5 years of age) with unknown serotype.

9. The Impact of Childhood Immunization
CDC estimates that vaccination of
U.S. children born between 1994
and 2016 will:
o Prevent 381 million illnesses
o Prevent 24.5 million
hospitalizations
o Help avoid 855,000 early deaths
o Save nearly $360 billion in direct
costs and $1.65 trillion in total
society costs
Updated data from previous article: Benefits from Immunization During the Vaccines for Children
Program Era – United States, 1994-2013. MMWR. 25 April 2014

10. Measles, mumps, and rubella vaccination
(minimum age: 12 months for routine vaccination)
Routine vaccination
• 2-dose series at 12–15 months, 4–6 years
• Dose 2 may be administered as early as 4 weeks after dose 1.

11. Measles, mumps, and rubella vaccination
(minimum age: 12 months for routine vaccination)
Catch-up vaccination
• Unvaccinated children and adolescents: 2 doses at least 4 weeks apart
• The maximum age for use of MMRV is 12 years.

12. Measles, mumps, and rubella vaccination
(minimum age: 12 months for routine vaccination)
Special situations
• International travel
• Infants age 6–11 months: 1 dose before departure; revaccinate with 2
doses at 12–15 months (12 months for children in high-risk areas) and
dose 2 as early as 4 weeks later.
• Unvaccinated children age 12 months and older: 2-dose series at least
4 weeks apart before departure

13. US measles cases top 700, highest total since 1994
• There have been 704 cases of measles reported by 22 states so far in 2019 — the greatest
number of measles cases in the United States since 1994, the CDC reported today (April 29,
2019).
• HHS Secretary Alex Azar noted that most of the cases have occurred among children aged
younger than 18 years who have not been vaccinated.
• CDC Director Robert R. Redfield, MD, noted that children aged younger than 5 years and older
adults are at the highest risk for severe complications from measles. Data in a newly released
MMWR revealed that of the cases reported this year, 9% have resulted in hospitalization and
3% have resulted in pneumonia. So far, there have been no deaths.
• Increase in Measles Cases — United States, January 1–April 26, 2019 MMWR / May 3, 2019 / 68(17);402–404

14. US measles cases top 700, highest total since 1994
• A high number of U.S. measles cases are the result of three large outbreaks. On Monday,
officials declared an end to an outbreak in Washington state, which accounted for 72 cases.
• Ongoing outbreaks in New York City and New York state are two of the largest and longest
lasting measles outbreaks in the U.S. in the 2000s, accounting for 592 total cases.
• According to the MMWR report, 44 U.S. measles cases in 2019 have been directly imported
from travelers who were unvaccinated or had unknown vaccination history before traveling,
including the index case in the New York City outbreak, a child who was infected on a trip to
Israel.

15. Measles Recent outbreaks and exposures
• WHO reports that before the measles vaccine was introduced in 1963, major
outbreaks were a common global occurrence, with two to three outbreaks
occurring annually. These outbreaks led to approximately 2.6 million deaths
each year.
• Since we have had access to the vaccine, we see much less measles. We
saw the numbers decrease to almost zero, but then in the last decade, we
have started to see an increase again. A lot of that has to do with people not
wanting to receive the vaccine.

16. Measles Recent outbreaks and exposures
• This increase has been evident on a global scale, with European Centre for Disease
Prevention and Control reporting 14,451 measles cases in 30 countries in 2017, a number
that more than triples the reported cases in 2016.
• Notable outbreaks also have occurred in the U.S. in the past few years. One of the more
pronounced outbreaks took place in two Disney theme parks in late 2014 and early 2015.
According to the CDC, 125 cases were connected to this outbreak between Dec. 28, 2014,
and Feb. 8, 2015.
• Of those who were residents of California at the time of infection (n = 110), 45% were
completely unvaccinated, and 43% had no record of immunization or their status was
unknown.

17. Nearly 1,000 Madagascar Children Dead of Measles
Since October 2018 - WHO
• At least 922 children and young adults have died of measles in Madagascar since October,
despite a huge emergency vaccination program, the World Health Organization (WHO).
• The number of deaths is based on official numbers, but these are likely to be very
incomplete, as is the current total of infections, at 66,000.
• The Indian Ocean island is among Africa's poorest countries, and in 2017 only 58 percent of
the population had been vaccinated against measles. The lack of a big outbreak since 2003
also means many have had no chance to develop immunity.
• Madagascar has Africa's highest children's malnutrition rate, at 47 percent. The condition
can increase the risk of serious complications and death from measles infection, the WHO
says.

18. U.S. Recorded 75 New Measles Cases in One Week
• The United States recorded 75 new measles cases last week, taking
confirmed cases for the year so far to 839, the worst outbreak since 1994,
federal health officials said on Monday, (5/13/2019).
• The U.S. Centers for Disease Control and Prevention said the number of
cases of the highly contagious and sometimes deadly disease rose by 9.8%
in the week ended May 10.

19. Inactivated poliovirus vaccination (minimum age: 6 weeks)
Routine vaccination
• 4-dose series at ages 2, 4, 6–18 months, 4–6 years; administer the final dose
on or after the 4th birthday and at least 6 months after the previous dose.
• 4 or more doses of IPV can be administered before the 4th birthday when a
combination vaccine containing IPV is used. However, a dose is still
recommended after the 4th birthday and at least 6 months after the previous
dose.

20. Inactivated poliovirus vaccination (minimum age: 6 weeks)
Catch-up vaccination
• In the first 6 months of life, use minimum ages and intervals only for travel to
a polio-endemic region or during an outbreak.
• IPV is not routinely recommended for U.S. residents 18 years and older.

21. Inactivated poliovirus vaccination (minimum age: 6 weeks)
• Series containing oral polio vaccine (OPV), either mixed OPV-IPV or OPV-only series:
• Total number of doses needed to complete the series is the same as that recommended
for the U.S. IPV schedule. See Guidance for Assessment of Poliovirus Vaccination Status
and Vaccination of Children Who Have Received Poliovirus Vaccine Outside the United
States.
• Only trivalent OPV (tOPV) counts toward the U.S. vaccination requirements. For
guidance to assess doses documented as “OPV,” see Errata: Vol. 66, No. 1.
• For other catch-up guidance, see Table 2.

22. Polio Outbreak Warning Upgraded in 5 Countries
• October 27th, 2018 – The US Centers for Disease Control and Prevention (CDC) published
5 separate Alert - Level 2, Practice Enhanced Precautions, regarding the increased
spreading of the polio virus.
• These CDC Travel Alerts for the Democratic Republic of the Congo, Nigeria, Papua New
Guinea, Somalia, and Syria note that progress had been made in these countries, but that
the contagious virus continues to spread.
• These outbreaks are caused by vaccine-derived poliovirus (VDPV), a sign of low oral polio
vaccine coverage in the countries.
• A vaccine-derived poliovirus (VDPV) is a strain of the weakened poliovirus that was initially
included in oral polio vaccine (OPV) and that has changed over time and behaves more like
the wild or naturally occurring virus, says the CDC.

23. As Measles Returns, U.S. States Look to Cut Vaccine Exemptions
May 04, 2019
• Maine has one of the lowest vaccination rates in the country, with 5 percent of kindergartners
holding a non-medical exemption from vaccination, compared to a national average of 2
percent, according to CDC data.
• The World Health Organization has said at least 95 percent of a community must be
immunized against measles to achieve the herd immunity needed to protect those unable to
get the vaccine such as infants and people with compromised immune systems.
• California outlawed non-medical exemptions in 2015 after a measles outbreak was traced to
the Disneyland theme park. The state saw the proportion of kindergarten students who
received all mandated vaccines rise to 95.1 percent last year, from 92.8 percent in 2015.

24. As Measles Returns, U.S. States Look to Cut Vaccine Exemptions
May 04, 2019
• Maine could soon prohibit parents from citing religious or personal beliefs to avoid
vaccinating their children, making the U.S. state one of a half dozen cracking down during
the nations' largest measles outbreak in 25 years.
• State legislatures in New York, New Jersey, Oregon, Vermont, Minnesota and Iowa, are
looking at similar bills, that would only allow exemptions from vaccinations for medical
reasons as determined by the child's doctor.
• Washington is poised to pass a bill that would remove exemptions on personal grounds for
the measles, mumps and rubella vaccine, while leaving in place a religious exemption.

25. What to Tell People Who Are Against Measles Vaccination
• The objections of anti-vaccinators have evolved. It used to be that the primary concerns anti-
vaccinators had were safety related, particularly the connection to autism, and distrust of the
pharmaceutical industry—that the pharmaceutical industry was pushing vaccines to make a lot of
money. Those are the old objections.
• One new argument is that natural is good. We're starting to see this—not in communities that are
poorly educated or don't understand much about vaccines, but in educated, upper-class, wealthy
communities.
• There are people out there who are saying that it's better to develop measles naturally than to receive
a vaccination. That's clearly false.
• Given the number of people who are hospitalized, the danger of brain damage, and the danger of
death—in some parts of the world, tens of thousands of people are dying from measles—there's
nothing good about developing a natural case of measles.

26. What to Tell People Who Are Against Measles Vaccination
• The other argument that's new is, "I have a right to do what I want to do." We see a lot of
individualism in our society now, with people saying, "You can't make me get a vaccine," or
"I'm not going to do it because I want to do what's best for me and my kids.“
• There are many people out there who can't vaccinate—newborns, immunocompromised
people, elderly people whose immune systems are getting weaker—and we have to protect
them.
• Related to that, when children are involved and need their vaccinations, the state does have
the right to say, "You must do this or you'll be fined."

27. NYC declares end to measles outbreak that sickened hundreds
September 4, 2019
• The New York City measles outbreak that sickened more than 600 people in Brooklyn and
Queens over the course of almost a year has ended, officials said.
• The outbreak was mostly confined to ultra-Orthodox Jewish residents with unvaccinated
children.
• Since the outbreak began in October 2018, the city spent over $6 million and dedicated more
than 500 staff to the response efforts.
• The outbreak totaled 654 cases, including 52 measles-related hospitalizations and 16 ICU
admission.

28. Ley de las Inmunizaciones Compulsorias a los Niños Pre-escolares y
Estudiantes en el Estado Libre Asociado de Puerto Rico
Ley Núm. 25 del 25 de septiembre de 1983
• Artículo 2. A partir de la vigencia de esta ley, ningún estudiante o niño pre-escolar podrá ser admitido o
matriculado en una escuela, centro de cuidado diurno, o centro de tratamiento social, si no está
debidamente inmunizado.
• Artículo 5. No se requerirá el certificado de inmunización para admisión o matricula de aquel
estudiante o niño pre-escolar que presente una declaración jurada de que él o sus padres pertenecen
a una organización religiosa cuyos dogmas confligen con la inmunización. La declaración jurada
deberá indicar el nombre de la religión o secta y deberá ser firmada por el estudiante, o sus padres, y
por el ministro de la religión o secta. Las exenciones por razones religiosas serán nulas en cualquier
caso de epidemia declarada por el Secretario de Salud. Igualmente no se requerirá certificado de
inmunización de aquel estudiante o niño pre-escolar que presente una certificación firmada por un
médico autorizado a ejercer la profesión en Puerto Rico a los efectos de que una o más de las
inmunizaciones requeridas por el Secretario de Salud pueden ser detrimentales para la salud del
estudiante. El certificado deberá indicar la razón específica y la posible duración de las condiciones o
circunstancias contraindicadas de la inmunización.

29. ADULT IMMUNIZATION SCHEDULE 2019
• The 2019 adult immunization schedule consists of:
• Figure 1. Recommended immunization schedule for adults by age group.
• Figure 2. Recommended immunization schedule for adults by medical
condition and other indications.
• Notes that accompany each vaccine containing important routine
vaccination information and considerations for special populations.

30. ADULT IMMUNIZATION SCHEDULE 2019
• In February 2019, the Recommended Immunization Schedule for Adults Aged 19 Years or
Older, United States, 2019 became effective, as recommended by the Advisory Committee
on Immunization Practices (ACIP) and approved by the Centers for Disease Control and
Prevention (CDC).
• The 2019 adult immunization schedule was also reviewed and approved by the following
professional medical organizations:
• American College of Physicians
• American Academy of Family Physicians
• American College of Obstetricians and Gynecologists

31. IMMUNIZATION SCHEDULE 2019
• CDC announced the availability of the 2019 adult immunization schedule at
www.cdc.gov/ vaccines/schedules/hcp/index.html in the Morbidity and
Mortality Weekly Report (MMWR).
• The schedule is published in its entirety in the Annals of Internal Medicine.
• The adult immunization schedule describes the age groups and medical
conditions and other indications for which licensed vaccines are
recommended.

32. ADULT IMMUNIZATION SCHEDULE 2019

33. ADULT IMMUNIZATION SCHEDULE 2019

34. ADULT IMMUNIZATION SCHEDULE 2019

35. ADULT IMMUNIZATION SCHEDULE 2019

36. INFLUENZA VACCINATION
Routine vaccination
• Persons age 6 months or older: 1 dose IIV, RIV, or LAIV appropriate for
age and health status annually
• For additional guidance, see www.cdc.gov/flu/ professionals/index.htm

37. INFLUENZA VACCINATION
Special situations
• Egg allergy, hives only: 1 dose IIV, RIV, or LAIV appropriate for age and
health status annually.
• Egg allergy more severe than hives (e.g., angioedema, respiratory
distress): 1 dose IIV, RIV, or LAIV appropriate for age and health status
annually in medical setting under supervision of health care provider who can
recognize and manage severe allergic conditions.

38. INFLUENZA VACCINATION
• Immunocompromising conditions (including HIV infection), anatomical
or functional asplenia, pregnant women, close contacts and caregivers
of severely immunocompromised persons in protected environment,
use of influenza antiviral medications in previous 48 hours, with
cerebrospinal fluid leak or cochlear implant: 1 dose IIV or RIV annually
(LAIV not recommended)
• History of Guillain-Barré syndrome within 6 weeks of previous dose of
influenza vaccine: Generally should not be vaccinated

39. Flu broke records for deaths, illnesses in 2017-2018 season
• Flu killed and hospitalized more people in the United States last winter than
any seasonal influenza in decades, according to new data released.
• Influenza killed about 80,000 people in the 2017-2018 season, according to
figures released by the Centers for Disease Control and Prevention.
• The flu killed 180 children last season. Only the 2009 swine flu pandemic,
which killed 358 children, was worse, in the 14 years since health authorities
began tracking child deaths from flu .

40. Influenza Temporada 2018-2019
Casos totales reportados
(Incluye hospitalizaciones)
10,551
Regiones de salud
con tasas más altas
Bayamón
Fatalidades 0
Hospitalizaciones 491
(Fuente: Departamento de Salud de PR)
Enero 2019

41. Influenza Season Now Longest in a Decade, CDC Reports
April 22, 2019
• According to this week’s FluView report, influenza activity continues to
decrease, with levels of influenza-like-illness (ILI) dropping further to 1.8% as
the 2018-2019 season winds down.
• Only three states continue to report widespread flu activity, however, another
five flu-related pediatric deaths were reported to CDC, bringing the total of
number of flu-related deaths in children this season 101.

42. ZOSTER VACCINATION
Routine vaccination
• Age 50 years or older: 2-dose series RZV 2–6 months apart (minimum
interval: 4 weeks; repeat dose if administered too soon) regardless of
previous herpes zoster or previously received ZVL (administer RZV at least 2
months after ZVL)
• Age 60 years or older: 2-dose series RZV 2–6 months apart (minimum
interval: 4 weeks; repeat dose if administered too soon) or 1 dose ZVL if not
previously vaccinated (if previously received ZVL, administer RZV at least 2
months after ZVL); RZV preferred over ZVL

43. ZOSTER VACCINATION
Special situations
• Pregnancy: ZVL contraindicated; consider delaying RZV until after
pregnancy if RZV is otherwise indicated
• Severe immunocompromising conditions (including HIV infection
with CD4 count <200 cells/ μL): ZVL contraindicated; recommended
use of RZV under review

44. HUMAN PAPILLOMAVIRUS VACCINATION
Routine vaccination
• Females through age 26 years and males through age 21 years: 2- or 3-dose series HPV
vaccine depending on age at initial vaccination; males age 22 through 26 years may be
vaccinated based on individual clinical decision (HPV vaccination routinely recommended at
age 11–12 years)
• Age 15 years or older at initial vaccination: 3-dose series HPV vaccine at 0, 1–2, 6
months (minimum intervals: 4 weeks between doses 1 and 2, 12 weeks between doses 2
and 3, 5 months between doses 1 and 3; repeat dose if administered too soon)

45. HUMAN PAPILLOMAVIRUS VACCINATION
Routine vaccination
• Age 9 through 14 years at initial vaccination and received 1 dose, or 2
doses less than 5 months apart: 1 dose HPV vaccine
• Age 9 through 14 years at initial vaccination and received 2 doses at
least 5 months apart: HPV vaccination complete, no additional dose
needed
• If completed valid vaccination series with any HPV vaccine, no additional
doses needed

46. HUMAN PAPILLOMAVIRUS VACCINATION
Special situations
• Immunocompromising conditions (including HIV infection) through age 26 years: 3-
dose series HPV vaccine at 0, 1–2, 6 months as above
• Men who have sex with men and transgender persons through age 26 years: 2- or 3-
dose series HPV vaccine depending on age at initial vaccination as above
• History of sexual abuse or assault: Start at age 9 years
• Pregnancy through age 26 years: HPV vaccination not recommended until after
pregnancy; no intervention needed if vaccinated while pregnant; pregnancy testing not
needed before vaccination

47. HPV vaccination is the best way to protect
children from cancers caused by HPV
*Estimated coverage with ≥1 dose of human papillomavirus (HPV) vaccine among adolescents aged 13-17
years, National Immunization Survey–Teen (NIS–Teen), United States, 2016 Source: MMWR August 25, 2017

48. Vaccine reduces HPV prevalence among teen girls by 86% in 10 years
April 30, 2019
• Within 10 years of vaccine introduction, HPV prevalence decreased 86% among females
aged 14 to 19 years in the United States, and 71% in women aged 20 to 24 years, according
to study findings presented at the CDC’s Epidemic Intelligence Service, or EIS, conference.
• According to the study, McClung and colleagues used the National Health and Nutrition
Examination Survey to evaluate quadrivalent vaccine (4vHPV)-type prevalence among 4,674
females in the pre-vaccine (2003–2006) and vaccine (2013–2016) eras overall and by race
and ethnicity.
• In the younger cohort, the 4vHPV-type prevalence decreased from 11.5% to 1.8% from the
prevaccine to vaccine era (adjusted PR = 0.14; 95% CI, 0.08–0.24), with steep declines seen
in all three groups. In the older cohort, prevalence decreased from 18.5% to 5.3% (aPR =
0.29; 95% CI, 0.15–0.56).

49. FDA Expands Gardasil to Include Adults up to Age 45
October 05, 2018
• The US Food and Drug Administration (FDA) has approved a supplemental application for
Merck's 9-valent human papillomavirus vaccine (Gardasil 9) to include women and men
aged 27 through 45 years.
• The Centers for Disease Control and Prevention has stated that HPV vaccination prior to
becoming infected with the HPV types covered by the vaccine has the potential to prevent
more than 90% of these cancers, or 31,200 cases every year, from ever developing.
• The CDC estimates that every year about 14 million Americans become infected with HPV.
About 12,000 women are diagnosed with cervical cancer and about 4000 women die from
cervical cancer caused by certain HPV viruses. HPV is also associated with several other
forms of cancer affecting men and women.
• Gardasil 9 was first approved for use in males and females aged 9 through 26 years.

50. FDA Expands Gardasil to Include Adults up to Age 45
October 05, 2018
• According to the FDA, in a study in roughly 3200 women between 27 and 45 years old
followed for an average of 3.5 years, Gardasil was 88% effective in preventing the combined
endpoint of persistent infection, genital warts, vulvar and vaginal precancerous lesions,
cervical precancerous lesions, and cervical cancer related to HPV types covered by the
vaccine.
• Effectiveness of Gardasil 9 in men 27 through 45 years of age is inferred from the data
described above in women 27 through 45 years of age, as well as efficacy data from
Gardasil in younger men (16 through 26 years of age) and immunogenicity data from a
clinical trial in which 150 men, 27 through 45 years of age, received a 3-dose regimen of
Gardasil over 6 months," the agency said.

51. HUMAN PAPILLOMAVIRUS VACCINATION
UPDATED Aug 2019
• Adults aged >26 years. Catch-up HPV vaccination is not recommended for
all adults aged >26 years. Instead, shared clinical decision-making regarding
HPV vaccination is recommended for some adults aged 27 through 45 years
who are not adequately vaccinated. HPV vaccines are not licensed for use in
adults aged >45 years.

52. PNEUMOCOCCAL VACCINATION
Routine vaccination
• Age 65 years or older (immunocompetent):
• 1 dose PCV13 if previously did not receive PCV13, followed by 1 dose PPSV23 at
least 1 year after PCV13 and at least 5 years after last dose PPSV23
• Previously received PPSV23 but not PCV13 at age 65 years or older: 1 dose PCV13
at least 1 year after PPSV23
• When both PCV13 and PPSV23 are indicated, administer PCV13 first (PCV13 and
PPSV23 should not be administered during same visit)

53. ACIP changes recommendations for pneumococcal vaccines
June 28, 2019
• In a close vote, members decided not to recommend the 13-valent pneumococcal conjugate
vaccine (Prevnar13, Pfizer; PCV13) for all adults age 65 or older who have not previously
received it, reversing a 2014 recommendation. Instead, they recommended that the decision
be left to doctors and patients.
• The 8-6 vote against recommending PCV13 for all older adults follows continued reductions
in PCV13-type disease due to the indirect effects from pediatric PCV13 use, which the
committee foresaw as potentially limiting the 2014 recommendation’s utility, leading to the
new vote.

54. PNEUMOCOCCAL VACCINATION
Special situations
• Age 19 through 64 years with chronic medical conditions (chronic heart
[excluding hypertension], lung, or liver disease; diabetes), alcoholism,
or cigarette smoking:
• 1 dose PPSV23

55. PNEUMOCOCCAL VACCINATION
• Age 19 years or older with immunocompromising conditions (congenital or acquired
immunodeficiency [including B- and T-lymphocyte deficiency, complement
deficiencies, phagocytic disorders, HIV infection], chronic renal failure, nephrotic
syndrome, leukemia, lymphoma, Hodgkin disease, generalized malignancy, iatrogenic
immunosuppression [e.g., drug or radiation therapy], solid organ transplant, multiple
myeloma) or anatomical or functional asplenia (including sickle cell disease and other
hemoglobinopathies):
• 1 dose PCV13 followed by 1 dose PPSV23 at least 8 weeks later, then another dose
PPSV23 at least 5 years after previous PPSV23;
• at age 65 years or older, administer 1 dose PPSV23 at least 5 years after most recent
PPSV23 (note: only 1 dose PPSV23 recommended at age 65 years or older)

56. PNEUMOCOCCAL VACCINATION
• Age 19 years or older with cerebrospinal fluid leak or cochlear implant:
• 1 dose PCV13 followed by 1 dose PPSV23 at least 8 weeks later;
• at age 65 years or older, administer another dose PPSV23 at least 5
years after PPSV23 (note: only 1 dose PPSV23 recommended at age 65
years or older)

57. Schramm v. Lyon
285 Ga. 72 (Ga. 2009) • 673 S.E.2d 241
• In 1982, Betty Lyon had her spleen removed as a result of injuries she received in an
automobile accident.
• In September 2004, Lyon developed overwhelming post-splenectomy infection (OPSI), a
condition which resulted in significant physical injuries, including the amputation of parts of
her arms and legs.
• Lyon filed a medical malpractice action on August 29, 2006, against eight physicians and
their practices who had treated her in the five years prior to the filing of the action.
• The complaint as subsequently amended alleged that each doctor failed to advise and warn
her about the risk of developing OPSI, failed to inform her of preventative measures she
should have taken to reduce the risk of developing OPSI, and failed to prescribe appropriate
medications and vaccinations which would have prevented infections that can lead to OPSI.