What are the indications for pneumococcal vaccination (PCV13 and PPSV23) in children and adults, including age groups and risk factors?

Pneumococcal Vaccine Indications

All adults aged ≥65 years should receive PPSV23, while PCV13 is no longer routinely recommended for this age group but may be considered through shared clinical decision-making for those without immunocompromising conditions, CSF leaks, or cochlear implants. 1

Adults Aged ≥65 Years

PPSV23 is universally recommended for all adults aged ≥65 years as a single dose 1. If a dose of PPSV23 was received before age 65, one additional dose should be given at age ≥65 years, provided at least 5 years have elapsed since the previous PPSV23 dose. No further doses are needed after vaccination at age ≥65 years 1.

PCV13 recommendations changed significantly in 2019. PCV13 is no longer routinely recommended for all adults aged ≥65 years. Instead, it is now based on shared clinical decision-making for immunocompetent adults aged ≥65 years without CSF leaks or cochlear implants 1. This change reflects that indirect protection from pediatric PCV13 vaccination has reduced PCV13-type disease to historically low levels in older adults, with minimal additional population-level benefit from universal adult vaccination 1.

Timing for Adults ≥65 Years

• If PCV13 is given, administer it before PPSV23
• Wait ≥1 year between PCV13 and PPSV23 for immunocompetent adults 1
• If PPSV23 was already given, PCV13 can be administered ≥1 year after the last PPSV23 dose 1

Adults Aged 19-64 Years with High-Risk Conditions

Immunocompromising Conditions (Definitive PCV13 + PPSV23 Recommendation)

Adults with the following conditions MUST receive both PCV13 and PPSV23 1:

• Congenital or acquired immunodeficiencies (B-cell/T-cell deficiency, complement deficiencies particularly C1-C4, phagocytic disorders)
• HIV infection
• Chronic renal failure or nephrotic syndrome
• Congenital or acquired asplenia
• Sickle cell disease or other hemoglobinopathies
• Generalized malignancy
• Hodgkin disease, leukemia, lymphoma, multiple myeloma
• Solid organ transplant
• Iatrogenic immunosuppression (long-term systemic corticosteroids, chemotherapy, radiation therapy)

Vaccination sequence for immunocompromised adults:

1. Give PCV13 first
2. Follow with first dose of PPSV23 ≥8 weeks after PCV13 1, 2
3. Give second dose of PPSV23 5 years after the first PPSV23 dose (for ages 19-64 years only) 1
4. At age ≥65 years, give one final PPSV23 dose if ≥5 years have passed since the previous PPSV23 1

CSF Leak or Cochlear Implant (Definitive PCV13 + PPSV23 Recommendation)

Adults with CSF leaks or cochlear implants require both vaccines 1:

1. Give PCV13 first
2. Follow with PPSV23 ≥8 weeks after PCV13 1
3. At age ≥65 years, give PPSV23 if ≥5 years since previous PPSV23 and ≥8 weeks after PCV13 1

Chronic Medical Conditions (PPSV23 Only for Ages 19-64)

Adults aged 19-64 years with the following conditions should receive PPSV23 only (PCV13 not routinely recommended) 1:

• Chronic heart disease (including congestive heart failure and cardiomyopathies)
• Chronic lung disease (COPD, emphysema, asthma)
• Chronic liver disease
• Diabetes mellitus
• Alcoholism
• Cigarette smoking

For these immunocompetent adults with chronic conditions:

• Give one dose of PPSV23 between ages 19-64 years 1
• At age ≥65 years, give one additional PPSV23 dose if ≥5 years have passed since the previous dose 1
• PCV13 may be considered through shared clinical decision-making at age ≥65 years 1

Children and Adolescents

PCV13 is routinely recommended for all children as part of the standard immunization schedule 3. The pneumococcal vaccine footnote in pediatric schedules itemizes recommendations for PCV13 and PPSV23 use in children and adolescents at increased risk based on age and degree of risk 3.

Children with high-risk conditions (immunocompromising conditions, asplenia, CSF leak, cochlear implant) should receive both PCV13 and PPSV23 according to age-specific schedules 3.

Key Clinical Pitfalls to Avoid

1. Do not give PCV13 and PPSV23 simultaneously - they should never be coadministered 1

2. Sequence matters for high-risk patients - Always give PCV13 before PPSV23 in vaccine-naïve patients with immunocompromising conditions, CSF leaks, or cochlear implants 1, 2

3. Minimum intervals are critical:

   • For immunocompromised: ≥8 weeks between PCV13 and PPSV23 1
   • For immunocompetent: ≥1 year between pneumococcal vaccines 1
   • Between PPSV23 doses: ≥5 years 1

4. Don't over-vaccinate - No additional PPSV23 doses are needed after the dose given at age ≥65 years 1

5. Shared clinical decision-making is not a universal recommendation - For healthy adults aged ≥65 years, PCV13 is optional and should be discussed individually, considering exposure risk and underlying conditions 1. The 2019 guideline change reflects that routine PCV13 for all older adults is no longer cost-effective given herd immunity from pediatric vaccination 1.