What are the guidelines for administering a second pneumococcal (Pneumococcal Conjugate Vaccine (PCV) or Pneumococcal Polysaccharide Vaccine (PPSV)) vaccine in the elderly population?

From the Guidelines

The current recommendation for a second pneumococcal vaccine in the elderly is to administer a single dose of PCV21, PCV20, or PPSV23, with the specific vaccine and timing dependent on the individual's previous vaccination history and health status, as outlined in the 2024 guidelines from the Advisory Committee on Immunization Practices 1. When considering the administration of a second pneumococcal vaccine, several factors must be taken into account, including the patient's age, previous vaccination history, and the presence of any immunocompromising conditions.

• For adults aged 65 and older who have not previously received pneumococcal vaccines, the recommended approach is to administer a single dose of PCV21, PCV20, or PCV15, with PCV15 followed by a dose of PPSV23 at least one year later 1.
• For those who previously received PPSV23, a dose of PCV21, PCV20, or PCV15 should be administered at least one year after the most recent PPSV23 dose 1.
• In cases where the patient has received both PCV13 and PPSV23 but not a final dose of PPSV23 at age 65 or older, shared clinical decision-making is recommended to determine whether to administer a single dose of PCV21 or PCV20, with administration at least 5 years after the last pneumococcal vaccine dose 1. The guidelines emphasize the importance of considering the individual's specific health status and vaccination history when determining the best approach for pneumococcal vaccination, and recommend reviewing the pneumococcal vaccination recommendations again when the person reaches age 65 years 1. Key points to consider include:
• The use of PCV21, PCV20, or PCV15 as the initial vaccine, with PCV15 followed by PPSV23 at least one year later 1.
• The administration of a single dose of PCV21, PCV20, or PPSV23 for those who previously received PPSV23, at least one year after the most recent PPSV23 dose 1.
• The consideration of shared clinical decision-making for individuals who have received both PCV13 and PPSV23 but not a final dose of PPSV23 at age 65 or older 1.

From the FDA Drug Label

Immunogenicity of Prevnar 20 in Individuals Previously Vaccinated With Pneumococcal Vaccine A randomized, open-label clinical trial (Study 6) described immune responses to Prevnar 20 in individuals 65 years of age and older previously vaccinated with PPSV23 (≥1 to ≤5 years prior to enrollment), previously vaccinated with Prevnar 13 (≥6 months prior to enrollment), or previously vaccinated with Prevnar 13 followed by PPSV23 (with PPSV23 vaccination ≥1 year prior to enrollment).

The guidelines for giving a second pneumococcal vaccine in the elderly are not explicitly stated in the provided drug label. However, it can be inferred that:

• Prevnar 20 can be administered to individuals 65 years of age and older who have previously received PPSV23 or Prevnar 13.
• The immune responses to Prevnar 20 were measured in individuals who received PPSV23 1 to 5 years prior to Prevnar 20, and in those who received Prevnar 13 at least 6 months previously.
• The OPA GMTs in participants who received PPSV23 1 to 5 years prior to Prevnar 20 were diminished compared to those who received Prevnar 13 at least 6 months previously. It is recommended to consult the healthcare professional for the most recent prescribing information and guidance on administering a second pneumococcal vaccine in the elderly 2.

From the Research

Guidelines for Second Pneumococcal Vaccine in the Elderly

• The Advisory Committee on Immunization Practices (ACIP) recommends a single dose of pneumococcal conjugate vaccine (PCV) for all PCV-naïve adults aged ≥50 years 3.
• For adults who have already received a PCV, the ACIP recommends additional doses of PCV based on the individual's risk factors and vaccination history 3.
• Studies have shown that coadministration of PCV and quadrivalent inactivated influenza vaccine (QIV) is safe and effective in adults ≥50 years old who have been preimmunized with 23-valent pneumococcal polysaccharide vaccine (PPSV23) 4.
• Sequential vaccination with PCV followed by PPSV23 has been shown to elicit robust immune responses without evidence of hyporesponsiveness 5.
• Dual vaccination with PCV and PPSV23 has been associated with a decrease in the rate of pneumococcal pneumonia and "other" pneumonia compared to PPSV23 alone 6.

Vaccination Schedules

• The ACIP recommends that adults aged ≥50 years who have not received a PCV should receive a single dose of PCV 3.
• Adults who have already received a PCV should follow the recommended vaccination schedule based on their individual risk factors and vaccination history 3.
• PCV and QIV can be administered concomitantly to adults ≥50 years of age who have been preimmunized with PPSV23 4.
• Sequential vaccination with PCV followed by PPSV23 can be used to provide broad protection against pneumococcal disease 5.

Special Considerations

• Adults with risk conditions for pneumococcal disease, such as immunocompromising conditions or chronic lung disease, may require additional doses of PCV or PPSV23 3.
• The safety and efficacy of PCV and PPSV23 in adults with certain medical conditions, such as kidney or liver disease, should be carefully considered before vaccination 4, 5.