Can the inactivated influenza vaccine, pneumococcal vaccine (PCV13/PCV15 or PPSV23), and recombinant zoster vaccine (RZV) be administered together in one visit?

Yes, influenza, pneumococcal, and shingles vaccines can and should be administered together at the same visit.

The CDC explicitly recommends routine concomitant administration of pneumococcal vaccines with other age-appropriate vaccines, including influenza and COVID-19 vaccines, at the same visit for adults with no specific contraindications 1. This approach maximizes vaccination coverage and prevents missed opportunities.

Key Evidence Supporting Concomitant Administration

Pneumococcal and Influenza Vaccines

The FDA drug label and clinical trials demonstrate that pneumococcal conjugate vaccine (PCV13) administered concomitantly with inactivated influenza vaccine (both trivalent and quadrivalent formulations) in adults ≥50 years showed:

• Non-inferior immune responses for all pneumococcal serotypes 2
• Non-inferior immune responses for all influenza strains 2
• Safety profile consistent with each vaccine given alone 2

A 2024 Chinese study confirmed non-inferior immunogenicity when IIV4 and PPSV23 were co-administered in adults ≥60 years, with favorable safety profiles 3.

Recombinant Zoster Vaccine (RZV) with Pneumococcal Vaccine

A 2022 phase IIIB randomized trial (NCT03439657) evaluated RZV co-administered with PCV13 in adults ≥50 years 4:

• Non-inferiority was met for both vaccines' immune responses
• RZV vaccine response rate was 99.1% with co-administration
• Local adverse events were consistent with each vaccine's known profile
• General adverse events were within the same range as RZV alone

RZV with Other Vaccines

Real-world data from 2017-2023 showed that 24.2% of 1.6 million patients received RZV co-administered with other vaccines, most commonly influenza (65.1%) 5. While this study noted slightly lower series completion rates with co-administration, the CDC and FDA prioritize preventing missed vaccination opportunities over theoretical concerns about completion rates.

Practical Implementation

Administer all three vaccines during the same visit using different injection sites and separate syringes 1, 2:

• Use different anatomic sites (e.g., deltoid muscles of different arms, or deltoid and thigh)
• Never mix vaccines in the same syringe
• Document each vaccine separately

Important Caveats

Timing Considerations for PPSV23

The 2020 ACIP guidelines note that PCV13 and PPSV23 should not be administered during the same visit when both are indicated 6. However, this applies specifically to the sequential PCV13→PPSV23 regimen. The newer 2023 guidelines recommend single-dose PCV20 or PCV21 for most adults, eliminating this concern 1.

RZV Series Completion

While co-administration is safe and effective, ensure patients understand RZV requires a second dose 2-6 months later. Real-world data shows 36% of patients who received only one RZV dose had a missed opportunity for the second dose during subsequent influenza or pneumococcal vaccination visits 7.

Clinical Algorithm

For adults ≥50 years presenting for vaccination:

1. Check vaccination history

   • If PCV-naïve: Give PCV20 or PCV21 (single dose) 8
   • If RZV-naïve: Give RZV dose 1 (schedule dose 2 in 2-6 months)
   • If due for annual influenza: Give current season's vaccine

2. Administer all indicated vaccines at the same visit using different injection sites

3. Do NOT delay any vaccine to give them separately unless specific contraindications exist (e.g., severe allergic reaction to vaccine components)

4. Schedule RZV dose 2 and document clearly to prevent missed opportunities

This approach is supported by the highest-quality evidence from ACIP guidelines 1, FDA drug labels 2, and recent randomized controlled trials 4, all prioritizing disease prevention through maximizing vaccination coverage.