When are the 20‑valent pneumococcal conjugate vaccine (PCV20), the 23‑valent pneumococcal polysaccharide vaccine (PPSV23), the 13‑valent pneumococcal conjugate vaccine (PCV13), and the recombinant zoster vaccine (Shingrix) indicated?

Pneumococcal Vaccination Indications

Adults ≥65 Years

All adults aged 65 years and older should receive pneumococcal vaccination with a single dose of PCV20, PCV21, or PCV15 (if PCV15 is used, follow with PPSV23 ≥1 year later). 1

Vaccination Strategy by Prior History:

• No prior pneumococcal vaccine or PCV7 only: Give PCV20, PCV21, or PCV15 (if PCV15, add PPSV23 ≥1 year later; minimum 8 weeks interval acceptable for immunocompromised, cochlear implant, or CSF leak patients) 1

• PPSV23 only: Give PCV20, PCV21, or PCV15 ≥1 year after last PPSV23 dose 1

• PCV13 only: Give PCV20, PCV21, or PPSV23 ≥1 year after PCV13 (for immunocompromised/cochlear implant/CSF leak: PPSV23 can be given ≥8 weeks after PCV13) 1

• PCV13 + PPSV23 at age ≥65: Shared clinical decision-making for additional PCV20 or PCV21 dose ≥5 years after last vaccine 1

Important caveat: PCV13 is no longer routinely recommended for all adults ≥65 years as of 2019, only via shared clinical decision-making, due to minimal population-level impact from routine use 2. The newer conjugate vaccines (PCV20/PCV21) are now preferred.

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Adults 19-64 Years with Immunocompromising Conditions, CSF Leak, or Cochlear Implant

These high-risk adults require pneumococcal vaccination regardless of age. 1

Immunocompromising conditions include: chronic renal failure, nephrotic syndrome, immunodeficiency, iatrogenic immunosuppression, generalized malignancy, HIV, Hodgkin disease, leukemia, lymphoma, multiple myeloma, solid organ transplant, congenital or acquired asplenia, sickle cell disease, or other hemoglobinopathies 1

Vaccination Strategy:

• No prior vaccine or PCV7 only: Give PCV20, PCV21, or PCV15 (if PCV15, follow with PPSV23 ≥8 weeks later) 1

• PPSV23 only: Give PCV20, PCV21, or PCV15 ≥1 year after last PPSV23 1

• PCV13 only: Give PCV20, PCV21, or PPSV23 (if PCV20/21: ≥1 year after PCV13; if PPSV23: ≥8 weeks after PCV13, then consider PCV20/21 ≥5 years later) 1

• PCV13 + 1 PPSV23 dose: Give PCV20 or PCV21 ≥5 years after last vaccine (completes series) 1

Critical timing note: For patients starting immunosuppressive therapy, administer vaccines before therapy initiation when possible 3

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Adults 19-64 Years with Chronic Medical Conditions

Adults with chronic conditions should receive pneumococcal vaccination. 1, 4

Chronic conditions include: alcoholism, chronic heart disease (including CHF and cardiomyopathies), chronic liver disease, chronic lung disease (COPD, emphysema, asthma), cigarette smoking, or diabetes mellitus 1

Vaccination Strategy:

• No prior vaccine or PCV7 only: Give PCV20, PCV21, or PCV15 (if PCV15, follow with PPSV23 ≥1 year later) 1

• PPSV23 only: Give PCV20, PCV21, or PCV15 ≥1 year after last PPSV23 1

• PCV13 only: Give PCV20, PCV21, or PPSV23 ≥1 year after PCV13 1

• PCV13 + PPSV23: Review recommendations again at age 65 1

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Shingrix (Recombinant Zoster Vaccine) Indications

Shingrix is indicated for all adults aged ≥50 years, with routine recommendation for those ≥60 years. 5, 6

Specific Indications:

• All adults ≥60 years: Routine recommendation 5

• Adults ≥50 years with risk factors: Including COPD, asthma, or other chronic lung diseases (increased risk of herpes zoster complications) 5, 6

• Dosing schedule: 2-dose series administered intramuscularly 5

Key Timing Considerations:

• Prior varicella vaccine recipients: Can receive Shingrix 5

• Prior ZVL (live zoster vaccine) recipients: Can receive Shingrix for improved protection (vaccine effectiveness 75.5% against herpes zoster) 5

• Concomitant administration: Can be given with influenza vaccine or PPSV23, though systemic side effects may be more frequent with simultaneous administration 5

• Live vaccine spacing: If not given concomitantly with other live parenteral vaccines, maintain ≥4 weeks interval 5

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Critical Pitfalls to Avoid

1. Sequential vaccination error: Giving PPSV23 before PCV diminishes subsequent PCV immune responses. Always give PCV first when both are indicated 7

2. Interval violations: Respect minimum intervals between vaccines—particularly the ≥1 year interval between PPSV23 and subsequent PCV doses in most scenarios 1

3. Serotype 4 consideration: In western US populations with high serotype 4 disease burden (≥30% of IPD), PCV20 may be preferred over PCV21, which lacks serotype 4 coverage 1

4. Immunosuppression timing: Vaccinate before starting immunosuppressive therapy when possible for optimal response 3

5. Misattribution of side effects: When co-administering Shingrix with other vaccines, patients may attribute Shingrix's systemic effects to the other vaccine, potentially reducing future vaccine acceptance 5