Table 1.

Comparison of the recommendations and funding for pneumococcal immunization outside routine vaccination programs for children in Western European countries

Country	Recommended vaccine	Region (date of recommendations)	Population (age, years)	Definition of risk	Funding	Additional information
Austria [28]	PCV13/PPV23	National (2014)	At risk and high risk (≥6)	High risk  Asplenia (anatomical, functional)  Chronic renal insufficiency  Cochlear implant  Complement and properdin deficiency  Hematopoietic organ disorder  HIV  Hypogammaglobulinemia  Immunodeficiency (congenital, acquired)  Liquor fistula  Nephritic syndrome  Nephrotic syndrome prior to immunosuppressive therapy  Neurological disorder (in children)  Sickle-cell anemia  Transplantation (organ, subsequent to stem cell transplantation) At risk  Body weight below third percentile (in infants and children)  Chronic cardiovascular disease (except hypertension)  Chronic respiratory disease  Cirrhosis  Diabetes  Metabolic disease  Neoplastic disease	Private	Naïve  PCV13 followed by PPV23 after ≥8 weeks Pre-vaccinated with PCV  After interval of ≥8 weeks 1xPPV23 Pre-vaccinated with PPV23  After interval of ≥8 weeks 1xPCV13 and after another interval of ≥8 weeks 1xPPV23 again (second PPV23 dose recommended ≥5 years after first PPV23 dose)  Investigations ongoing into necessity of further vaccinations
	PCV13/PPV23	National (2014)	All (≥50)	N/a	Private	Naïve  PCV13 followed by PPV23 after 1 year Pre-vaccinated with PCV13  After interval of ≥1 year 1xPPV23 Pre-vaccinated with PPV23  After interval of ≥2 years 1xPCV13  Investigations ongoing into necessity of further vaccinations
Belgium [29, 30]	PCV13/PPV23	National (2013)	High risk (≤17)	Asplenia Chronic disease (heart, lung, renal) Cochlear implant CSF leak Diabetes (non-stable) Immunodeficiency (congenital, immunosuppressant induced) Metabolic disease	Private	PCV13 (schedule depending on age) followed by PPV23 (revaccination every 5 years for asplenia)
			High risk (≥18)	Autoimmune disease/immune-mediated inflammatory disease Asplenia Cancer (hematological) Cochlear implant HIV Immunodeficiency Transplantation (organ)	Private	High-risk populations  PCV13 followed by PPV23 after at least 8 weeks and revaccination with PPV23 every 5 years Adults aged ≥50 years with certain co-morbidities and all ≥65 years  Either PPV23 with 1 revaccination after 5 years or PCV13 followed by PPV23 after 8 weeks with 1 revaccination after 5 years (except >75 years who do not require revaccination)
			At risk (≥50)	Alcoholism Chronic disease (heart, kidney, liver, respiratory) Smoking
			All (≥65)	N/a
Denmark [31]	PCV13	National (2012)	At risk (any age)	Asplenia (functional) Cochlear implant CSF leak History of IPD HIV Lymphoma Splenectomy (completed/planned) Transplantation (organ)	Limited subsidy (to cover vaccination of at-risk groups and some age groups)	For individuals at risk aged ≥6 years vaccination with PCV13 should be followed by 1 dose of PPV23 after ≥8 weeks
			At risk (<18)	Chronic lung disease Cyanotic heart disease Heart failure/insufficiency Hypodynamic respiratory insufficiency Immunodeficiency (excluding agammaglobulinemia and SCID) Nephrotic syndrome Palliative surgery for heart disease
			At risk (18–65)	Chronic disease (heart, kidney, liver, lung) Diabetes	Private	For individuals at risk vaccination with PCV13 should be followed by 1 dose of PPV23 ≥8 weeks after PCV13 vaccination
			All (≥65)	N/a
Finland [32]	PCV13	National (2013)	High risk (≥5)	Asplenia (anatomical, functional) Cochlear implant HIV Immunodeficiency (congenital, acquired) Liquor fistula Lymphoma Multiple myeloma Nephrotic syndrome Patients treated with systemic corticosteroids or other immunosuppressants Transplantation (organ and tissue)	Private (except stem cell transplantation patients)	PCV13 preferred in high-risk individuals (e.g., immunocompromised) and may be followed by PPV23. However, physicians can choose whether to give PCV13 or PPV23 PCV13 is funded for stem cell transplantation patients of all ages PCV13 may also be considered in healthy individuals of all ages
	PPV23		At risk or in permanent institutional care (≥5)	Chronic disease (cardiac, pulmonary) Diabetes (type 1) Hepatic insufficiency Patients treated with systemic corticosteroids or other immunosuppressants Renal insufficiency Transplantation (organ, tissue)		–
			All (≥65)	N/a
France [33]	PCV13	National (2013)	At risk (≥2)	Asplenia or hyposplenia Cancer treated by chemotherapy (solid tumor, hematological) Cochlear implant or planned cochlear implant HIV Immunodeficiency (congenital) Immunosuppressive therapy, biotherapy, or corticotherapy for autoimmune disease or chronic inflammation Meningeal fistula Nephrotic syndrome Transplantation or waiting for transplantation (organ, hematopoietic stem cell)	Public	For all at-risk individuals aged ≥2 years, PCV13 followed by PPV23 after ≥8 weeks In some cases the vaccination schedule may differ and there are slight differences for specific populations (for asplenic and immunosuppressed patients PCV is preferred), but PCV13 should be administered first in all cases For high-risk individuals aged ≥6 years to <50 years funding procedure ongoing
	PPV23		At risk (≥5)	Asthma (severe with continuous treatment) Chronic liver disease (alcoholic or non-alcoholic origin) Chronic respiratory failure COPD Cyanotic congenital heart disease Diabetes (not balanced by diet) Emphysema Heart failure Kidney failure	Public	–
Germany [34]	PCV	Saxony [35] (updated January 2014)	At risk (>2)	Asplenia Autoimmune disease Bone marrow transplantation Chronic disease (heart, kidney, respiratory) CSF leaks, cochlea implant HIV Hematological diseases Immunodeficiency (primary) Metabolic disease Neurological diseases in children Occupational risk (laboratory personnel at risk of infection, medical personnel in contact with patients) Sickle-cell anemia Transplantation (organ)	Public	All infants from the age of 2 months to 5 years should receive PCV (vaccination should be started in the third month of life, according to schedule of vaccine manufacturer) PCV may be PCV10 or PCV13 for those aged 2–<5 years; PCV will be PCV13 for those aged ≥5 years. Children with persisting risk for pneumococcal infection should be vaccinated in the third year of life with PPV23 in addition to PCV (interval of at least 2 months after last vaccination with PCV) Non-vaccinated infants (aged ≥5 years), adolescents and adults should receive one dose of PCV or PPV23 (according to approval) PCV can be supplemented with PPV23 if protection against further serotypes is required (interval at least 4 years) In those pre-vaccinated with PPV23, catch-up vaccination with PCV is useful (interval at least 5 years) In at-risk individuals and those aged ≥60 years revaccination with PPV23 is possible (≥5 years for adults, ≥3 years for children aged <10 years)
			All (≥60)	N/a
	PCV	National (PCV funding 2013; PCV recommendations 2014)	At risk (2–<5)	Chronic disease (e.g., heart, kidney, liver, respiratory diseases, metabolic disorders [e.g., diabetes], neurological diseases [e.g., cerebral pareses, seizure disorders]) Immunodeficiency (congenital, acquired, e.g., T cell, B cell or antibody deficiency, deficiency or functional disorders of myeloic cells [e.g., neutropenia, chronic granulomatosis, leukocyte adhesion or signal transduction defects], complement or properdin deficiency, functional hypersplenism or splenectomy, neoplastic diseases, HIV infection, bone marrow transplantation, immunosuppressive therapy [e.g., due to organ transplantation, autoimmune disease]) Anatomic risks, risks associated with foreign bodies for pneumococcal meningitis (e.g., liquor fistula, cochlea implant)		For this age group, PCV may be PCV10 or PCV13 For congenital or acquired immunodeficiencies, chronic renal diseases/nephrotic syndrome, revaccination can be considered every 5 years (for those aged >10 years) or every 3 years (for those aged <10 years)
	PCV13/PPV23	National (PCV funding 2013; PCV recommendations 2014; PPV 1982)	At risk (≥5)	Chronic disease (e.g., heart, kidney, liver, respiratory diseases, metabolic disorders [e.g., diabetes], neurological diseases [e.g., cerebral pareses, seizure disorders]) Immunodeficiency (congenital, acquired, e.g., T cell, B cell or antibody deficiency, deficiency or functional disorders of myeloic cells [e.g., neutropenia, chronic granulomatosis, leukocyte adhesion or signal transduction defects], complement or properdin deficiency, functional hypersplenism or splenectomy, neoplastic diseases, HIV infection, bone marrow transplantation, immunosuppressive therapy [e.g., due to organ transplantation, autoimmune disease]) Anatomic risks, risks associated with foreign bodies (e.g., liquor fistula, cochlea implant)		For this age group, PCV will be PCV13 For congenital or acquired immunodeficiencies, chronic renal diseases/nephrotic syndrome, revaccination can be considered every 5 years (for those aged >10 years) or every 3 years (for those aged <10 years)
	PPV23	National (1998)	All (≥60)	N/a
Greece [36]	PCV13	National (2011)	All (>50)	N/a	Public	–
Ireland [37]	PCV13/PPV23	National (2013)	Medium risk and high risk (2–<5)	Medium risk  Children <5 years of age following IPD  Chronic heart, lung, or liver disease  Chronic renal disease or nephrotic syndrome  Diabetes mellitus requiring insulin or oral hypoglycemic drugs  Down syndrome High risk  Asplenia, hyposplenia (including splenectomy, sickle-cell disease, hemoglobinopathies, and celiac disease)  Candidates for, or recipients of, a cochlear implant  Complement deficiency (particularly C1–C4)  CSF leaks (congenital or complicating skull fracture or neurosurgery)  Immunosuppressive conditions (e.g., some B and T cell disorders, HIV infection, leukemia, lymphoma) and those receiving immunosuppressive therapies  Intracranial shunt  Post-hematopoietic stem cell transplant  Solid organ transplant	PCV13 supplied free of charge to all those in risk groups; individuals pay an administration fee	2–5 years: 1 or 2 doses of PCV13 at 2-month intervals followed by 1 dose of PPV23 ≥2 months after final PCV dose
			High risk (5–<18; 18–64)	Asplenia, hyposplenia (including splenectomy, sickle-cell disease, hemoglobinopathies, and celiac disease) Candidates for, or recipients of, a cochlear implant Complement deficiency (particularly C1–C4) CSF leaks (congenital or complicating skull fracture or neurosurgery) Immunosuppressive conditions (e.g., some B and T cell disorders, HIV infection, leukemia, lymphoma) and those receiving immunosuppressive therapies Intracranial shunt Post-hematopoietic stem cell transplant Solid organ transplant	PCV13 supplied free of charge to all those aged <18 years in risk groups; individuals pay an administration fee PCV13 is not free of charge to those aged ≥18 years PPV23 supplied free of charge to all those in risk groups; individuals pay an administration fee unless they have a medical or doctor-only card	>5–<18 years: 0, 1 or 2 doses of PCV13 followed by 1 dose of PPV23 ≥2 months after PCV
	PPV23		Medium risk (5–<18)	Children <5 years of age following IPD Chronic heart, lung, or liver disease Chronic renal disease or nephrotic syndrome Diabetes mellitus requiring insulin or oral hypoglycemic drugs Down syndrome	Vaccine supplied free of charge to all those in risk groups; individuals pay an administration fee unless they have a medical or doctor-only card	1 Dose of PPV23
			Medium risk (18–64)	Chronic heart, lung, or liver disease Chronic renal disease or nephrotic syndrome Diabetes mellitus requiring insulin or oral hypoglycemic drugs Smokers and alcoholics Individuals with occupational exposure to metal fumes (i.e., welders)		–
			All (≥65)	N/a
Italy	PCV13/PPV23	Basilicata [38] (2012)	At risk (any age)	Chronic disease (heart, liver [hepatic cirrhosis], respiratory) Metabolic disease	Public	For at-risk adults aged <50 years, PCV13 is recommended in addition to PPV23. PPV23 should be administered after >8 weeks
			All (≥65)	N/a
		Bolzano [39] (2013)	At risk (any age)	Alcoholism Asplenia Chronic disease (cardiac, liver, pulmonary) Cirrhosis Cochlear implant Diabetes HIV Immunodeficiency Immunosuppression (clinically significant) Leukemia Liquor fistula Lymphoma Multiple myeloma Neoplastic spread Nephrotic syndrome SCID Thalassemia Transplantation (organ, bone marrow)	Public	–
			All (>65)	N/a
		Cagliari (LHU Cagliari 8) [40] (2011)	At risk (≥50)	Asplenia Chronic disease (heart, kidney, liver, respiratory) Cochlear implant CSF leak HIV Immunodeficiency Metabolic disease Other pathologies predisposed to high IPD risk Transplantation (organ)	Public	PCV13 recommended in addition to PPV23 PPV23 to be administered 8 weeks following PCV13
		Emilia Romagna [41] (2014)	At risk and high risk (any age)	High risk  Asplenia  Chronic disease (kidney [renal failure])  Cochlear implant  CSF leak  Hemoglobinopathy  HIV  Immunodeficiency (acquired)  Immunosuppression (iatrogenic)  Leukemia  Lymphoma  Multiple myeloma  Neoplastic spread  Nephrotic syndrome  Transplantation (organ, bone marrow) At risk  Alcoholism  Chronic disease (heart, liver [hepatic cirrhosis], respiratory)  Diabetes  Residents in an institution (e.g., nursing home) aged >65 years	Public	High-risk individuals  PCV13 recommended in addition to PPV23  PPV23 should be administered ≥8 weeks after PCV13; for bone marrow transplantation, 3 doses of PCV13 (interval 2 months); a fourth dose is recommended in case of chronic graft versus host disease
			In permanent institutional care (≥65)	N/a
		Friuili–Venezia Giulia [42] (2012)	At risk (≥18)	Asplenia Chronic disease (heart, kidney [renal failure], liver [hepatic cirrhosis], respiratory) CNS disease Metabolic disease Others	Public	PCV13 recommended in addition to PPV23 At-risk individuals: PCV13, 2 doses 8 weeks apart (3 doses for bone marrow transplantation)
			All (≥65)	N/a
		Lazio [43] (2012)	At risk (any age)	Asplenia Chronic disease (heart, kidney [renal failure], liver [hepatic cirrhosis], respiratory) CNS disease Metabolic disease	Public	–
		Liguria [44] (2013)	At risk (any age)	Asplenia Cancer (hematological) Chronic disease (heart, kidney [renal failure], liver [hepatic cirrhosis], respiratory) CSF leak Diabetes Immunodeficiency (congenital, acquired) Neoplastic spread Transplantation (organ, bone marrow)	Public	–
			All (>70)	N/a
		Lombardia (LHU Milan) [45] (2012)	At risk and high risk (>18)	High risk  Asplenia  Chronic disease (renal)  Cochlear implant  CSF leak  Hemoglobinopathy  HIV  Immunodeficiency (congenital, acquired)  Leukemia  Lymphoma  Multiple myeloma  Neoplastic spread  Previous IPD  Transplantation (organ, bone marrow) At risk  Chronic disease (heart, liver, pulmonary)  Diabetes	Public (PCV13 is available on medical prescription)	PCV13 recommended in addition to PPV23 PPV23 should be administered 8 weeks after PCV13 Individuals already vaccinated with PPV23 should be vaccinated with PCV13 1 year after PPV23 For adults aged <50 years PPV23 is recommended For adults aged ≥50 years PCV13 is recommended
			All (≥65)	N/a		PCV13 if not previously vaccinated
		Marche [46] (2013)	At risk (any age)	Asplenia Chronic disease (heart, kidney disease [renal failure], respiratory) Cochlear implant CSF leak Diabetes Hepatic cirrhosis and chronic liver disease due to alcoholism HIV Immunodeficiency (congenital, acquired) Immunosuppression (iatrogenic) Leukemia Lymphoma Multiple myeloma Neoplasia Thalassemia Transplantation (organ, bone marrow)	Public	–
		Piemonte [47] (2012)	At risk (>5)	Asplenia Chronic disease (heart [excluding hypertension], kidney [renal failure], liver, respiratory) Cochlear implant Complement deficiency CSF leak Diabetes (type 1) Hemoglobinopathy Immunodeficiency (congenital, acquired)	Private	PCV13 + PPV23 6 months apart
		Puglia [48] (2012)	At risk (≥50)	Asplenia Chronic disease (heart, kidney [renal failure], liver [hepatic cirrhosis], respiratory) Cochlear implant CSF leak Diabetes Hemoglobinopathy HIV Immunodeficiency (congenital, acquired) Leukemia Lymphoma Multiple myeloma Neoplasia	Public	–
			Cohort (65, 70, 75)	N/a
		Sicilia [49] (2012)	At risk (50–64)	Asplenia Chronic disease (heart, kidney [renal failure], liver [hepatic cirrhosis], respiratory) CNS disease Metabolic disease	Public	–
			Cohort (65, 75)	N/a
		Trento [50] (2012)	At risk or nursing home residents (any age)	Asplenia Chronic cardiac disease Chronic renal failure Cochlear implant COPD Diabetes HIV Immunodeficiency (congenital) Immunosuppression Liquor leakage Nephrotic syndrome SCID	Public	–
			All (>65)	N/a
		Tuscany LHU [51] (Local Directive to GPs—April 2012) (2012)	At risk or in permanent institutional care (≥6)	Asplenia Cardiac decompensation (severe) Chronic disease (hematopoietic, liver) Chronic renal failure COPD Diabetes Immunodeficiency	Public	–
			All (≥50)	N/a
		Umbria [52] (2012)	At risk or in permanent institutional care (≥50)	Asplenia Chronic disease (heart, kidney [renal failure], liver [hepatic cirrhosis], respiratory) CNS disease Metabolic disease	Public	–
		Veneto [53] (2012)	At risk (any age)	Asplenia Cancer (hematological, solid) Chronic disease (heart, kidney [renal failure], liver [hepatic cirrhosis], respiratory) CNS disease Immunodeficiency (primary) Metabolic disease Transplantation (organ)	Public	–
	PPV23	National [54] (2005)	At risk (any age)	Agammaglobulinemia Asplenia Asthma Autoimmune disease Cancer (hematological, solid tumor) Chronic disease (heart, kidney, liver, respiratory) Cyanotic heart disease Immunodeficiency (primary) Metabolic disease SCID Transplantation (organ)	Public	–
Luxembourg [55, 56]	PCV13	National (2011)	At risk (<5)	Asplenia Chronic disease (heart, liver, renal, respiratory [excluding asthma]) Cochlear implant CSF leak Diabetes HIV Immunocompromised Premature birth	Private	–
	PPV23	National (2008)	At risk or in permanent institutional care (≥18)	Alcoholism Asplenia Chronic disease (cardiovascular, renal, respiratory) Cirrhosis Cochlear implant CSF leak Diabetes HIV Liquor fistula Lymphoma Multiple myeloma Nephrotic syndrome Sickle-cell disease Transplantation (organ)		–
			All (>60)	N/a
Netherlands [57]	PCV13/PPV23	National (2012)	At risk (any age)	Asplenia	Private	1 Dose of PCV13 followed by 1 dose of PPV23 after ≥8 weeks PPV23 should be repeated once after 5 years
Norway [58, 59]	PCV13	National (2013)	At risk (any age)	Asplenia HIV Stem cell transplantation Considered for following groups after collective evaluation of risk: B cell deficiency Cancer (hematological) Cochlear implant CSF leak Transplantation (organ, bone marrow)	Public (for asplenia, HIV, and stem cell transplantation only)	PCV13 recommended only in addition to PPV23 Administer PCV13 ≥8 weeks prior to PPV23 For asplenia and HIV administer PPV23 in addition to PCV13 Repeat PPV23 every 5 years for asplenia and every 10 years for other risk groups
	PPV23		At risk (any age)	Asplenia B cell deficiency Cancer (hematological) Cochlear implant CSF leak HIV Transplantation (organ, bone marrow)
			All (≥65)	N/a
Portugal [60]	PCV13	National (2010)	At risk and high risk (<5, 59 months)	High risk  Asplenia (anatomical, functional)  Cochlear implant or cochlear implant placement planned  Down syndrome  HIV infection  Premature birth (≤28 weeks) Sickle-cell disease and other hemoglobinopathies Presumable high risk  Acquired immunodeficiency   Immunosuppressive therapy, prolonged corticosteroid therapy, chemotherapy, or radiotherapy   Hematological cancer, mainly lymphocytic leukemia (acute and chronic), Hodgkin disease and multiple myeloma  Bone marrow donor  Chronic disease (cardiac [cyanotic congenital cardiopathy, heart failure], liver, pulmonary [excluding asthma, except patients on high doses of corticosteroids])  Chronic renal failure  Congenital immunodeficiency  Diabetes  CSF fistula (congenital malformation, cranial fracture, or neurosurgery procedure)  Nephrotic syndrome  Organ or bone marrow transplantation	Public	–
	PPV23		At risk and high risk (2–17)	High risk  Asplenia (anatomical, functional)  Cochlear implant or cochlear implant placement planned  Down syndrome  HIV infection  Premature birth (≤28 weeks)  Sickle-cell disease and other hemoglobinopathies Presumable high risk  Acquired immunodeficiency   Immunosuppressive therapy, prolonged corticosteroid therapy, chemotherapy, or radiotherapy   Hematological cancer, mainly lymphocytic leukemia (acute and chronic), Hodgkin disease and multiple myeloma  Bone marrow donor  Chronic disease (cardiac [cyanotic congenital cardiopathy, heart failure], liver, pulmonary [excluding asthma, except patients on high doses of corticosteroids])  Chronic renal failure  Congenital immunodeficiency  Diabetes  CSF fistula (congenital malformation, cranial fracture, or neurosurgery procedure)  Nephrotic syndrome  Organ or bone marrow transplantation
Spain [61]	PCV13	National (2012)	At risk (≥50)	Cancer (hematological) Chemotherapy or immunosuppressive treatment HIV Nephrotic syndrome Renal insufficiency Transplantation (organ, hematopoietic cell)	Public	–
		Cataluña [62] (2014)	At risk (≥5)	Asplenia or asplenic dysfunction Cancer (hematological) Cochlear implant CSF leak HIV Immunodeficiency (congenital, acquired) Immunosuppressive treatment, including systemic steroids and radiotherapy Nephrotic syndrome Renal insufficiency Sickle-cell disease Transplantation
		Galicia [63] (2012)	At risk (≥50)	Asplenia Cancer (hematological) Chemotherapy or immunosuppressive treatment Chronic renal disease (stage ≥3) Cochlear implant CSF leak HIV Nephrotic syndrome Transplantation (organ, hematopoietic cell)
		Murcia [64] (2014)	At risk (≥6)	Asplenia or asplenic dysfunction B or T cell deficiency Cancer (hematological) Chemotherapy or radiotherapy Chronic liver disease (including cirrhosis) Chronic renal insufficiency (advanced) Complement deficiency Hemodialysis History of IPD HIV Phagocytosis dysfunction Transplantation (organ, hematopoietic cell)
			At risk (6–50)	Cochlear implant CSF leak
		Basque Country [65] (2013)	At risk (≥50)	Asplenia Cancer (hematological) Chemotherapy or immunosuppressive treatment Chronic renal insufficiency (advanced) Cochlear implant CSF leak Hemodialysis History of IPD HIV Immunodeficiency (congenital, acquired) Transplantation (organ, hematopoietic cell)
		Valencia [66] (2013)	At risk (≥18)	Asplenia or asplenic dysfunction B or T cell deficiency Cancer (hematological) Chemotherapy or radiotherapy Chronic renal disease (stage ≥3) Complement deficiency Cochlear implant CSF leak Hemodialysis HIV Nephrotic syndrome Phagocytosis dysfunction Transplantation (organ, hematopoietic cell)
		Madrid [67] (2013)	At risk (≥50)	Asplenia (including elective splenectomy and late complement component deficiency) Cancer (hematological) Chemotherapy or immunosuppressive treatment Chronic alcoholism Chronic liver disease Cirrhosis Coagulation factor concentrate recipients Cochlear implant CSF leak Hemodialysis HIV Nephrotic syndrome Renal disease (end-stage) Renal insufficiency Sickle-cell disease Transplantation (organ, hematopoietic cell)
		Navarra [68] (2013)	At risk (≥18)	Asplenia Cancer (hematological) Chemotherapy or immunosuppressive treatment HIV Nephrotic syndrome Renal insufficiency (severe) Transplantation (organ, hematopoietic cell)
		Extremadura [69] (2013)	At risk (≥50)	Cancer (hematological) Chemotherapy or immunosuppressive treatment HIV Nephrotic syndrome Renal insufficiency Transplantation (organ, hematopoietic cell)
	PPV23	All Spanish autonomous regions [70] (varies)	At risk or older adults in permanent institutional care (≥2 to ≤60/65)	Alcoholism Asplenia Cancer (hematological) Chronic disease (cardiovascular, respiratory) Cirrhosis Cochlear implant Diabetes HIV Nephrotic syndrome Renal insufficiency Sickle-cell disease Transplantation (organ)		Funded by Public Health of the different Spanish Regions Date of implementation differs between the 19 different autonomous regions
		Most Spanish autonomous regions [70] (varies)	All (≥60/≥65)	N/a		Recommended vaccination by age at time of influenza vaccination campaign Date of implementation varies between different regions
Sweden	PCV13/PPV23	Stockholm [71] (2013)	At risk (≥2)	Asplenia Cochlear implant Cystic fibrosis Immunosuppression (e.g., transplantation, receiving cytostatics or other medication severely affecting the immune system) Liquor fistula Nephrotic syndrome Transplantation (organ)	Public (for high-risk individuals)	Regional recommendations for high-risk individuals in Stockholm, PCV13 recommended followed by PPV23 after ≥8 weeks
	PPV23	National [72] (1994)	At risk (≥2)	Agammaglobulinemia Alcoholism Asplenia Asthma Autoimmune disease Cancer (hematological, solid tumor) Chronic disease (heart, kidney, liver, respiratory) Cyanotic heart disease CNS disease CSF leak Hemodynamically significant residual lesion after surgery Hemodynamic respiratory insufficiency History of IPD HIV Immunodeficiency (primary) Intracranial shunt Metabolic disease SCID Sickle-cell disease and other hemoglobinopathies Transplantation (organ)	Varies	Funding is decided by the local county council, in some areas vaccination of individuals aged ≥65 years is free of charge, in other areas it is partially subsidized, and in the remainder the full cost is paid by the individual
			All (≥65)	N/a
United Kingdom	PCV13 [73]	National (2013)	At risk (<5)	Asplenia Asthma (only if high-dose systemic steroids) Cancer (hematological, solid tumor) Chronic disease (heart, kidney, liver, respiratory) Cochlear implant CSF leak Diabetes (excludes diet controlled) HIV Immunosuppression Sickle-cell disease Transplantation (organ)	Via the National Health Service	–
			At risk—severely immunocompromised (≥5)	Genetic disorders severely affecting the immune system (e.g., IRAK-4, NEMO, complement deficiency) Leukemia (acute, chronic) Multiple myeloma Transplantation (bone marrow)
	PPV23 [73]	National (1992)	At risk (≥2)	Asplenia Asthma (only if high-dose systemic steroids) Cancer (hematological, solid tumor) Chronic disease (heart, kidney, liver, respiratory) Cochlear implant CSF leak Diabetes (excludes diet controlled) HIV Immunosuppression Sickle-cell disease Transplantation (organ)
		National (2003)	All (≥65)	N/a

CNS Central nervous system, COPD chronic obstructive pulmonary disease, CSF cerebrospinal fluid, GPs general practitioners, HIV human immunodeficiency virus, IPD invasive pneumococcal disease, LHU local health unit, N/a not applicable, PCV pneumococcal conjugate vaccine, PPV pneumococcal polysaccharide vaccine, SCID severe combined immunodeficiency