Should an 86-year-old patient who received Pneumovax (pneumococcal polysaccharide vaccine) 27 years ago get the new PCV23 (pneumococcal conjugate vaccine)?

Pneumococcal Vaccination Recommendation for an 86-Year-Old Patient with Prior Pneumovax

Yes, this 86-year-old patient who received Pneumovax (PPSV23) at age 59 should receive a single dose of PCV20 or PCV21 as recommended by the most recent ACIP guidelines. 1

Current Recommendation Based on Vaccination History

For an 86-year-old patient who received PPSV23 27 years ago (at age 59):

• The 2024 ACIP guidelines clearly recommend a single dose of PCV21, PCV20, or PCV15 to be administered ≥1 year after the last PPSV23 dose for adults with prior PPSV23 vaccination 1
• Since it has been 27 years since the patient's previous PPSV23 dose, they are well beyond the minimum 1-year interval requirement
• The most straightforward option is a single dose of PCV20 or PCV21, which would complete their pneumococcal vaccination series 1

Rationale for Recommendation

1. Age-based risk:

   • Adults aged ≥65 years are at high risk for invasive pneumococcal disease (IPD) and should receive pneumococcal vaccination regardless of health status 2
   • The patient's advanced age (86) places them at particularly high risk for pneumococcal disease complications

2. Time since previous vaccination:

   • The patient received PPSV23 27 years ago, which is well beyond the duration of protection
   • Antibody levels following PPSV23 decline rapidly, especially in older adults 3
   • The long interval since previous vaccination (27 years) means protection has likely waned significantly

3. Vaccine selection rationale:

   • PCV20 or PCV21 is preferred over PCV15 followed by PPSV23 for simplicity (single dose completion) 1
   • Conjugate vaccines (PCV20/PCV21) induce a T-cell dependent immune response that may provide better protection than polysaccharide vaccines in older adults 4

Implementation Considerations

• No minimum interval concerns exist in this case since the previous PPSV23 was given 27 years ago (far exceeding the minimum 1-year interval requirement)
• No additional doses of pneumococcal vaccine would be needed after administering PCV20 or PCV21 1
• If PCV20/PCV21 is unavailable, PCV15 could be given, but would ideally be followed by PPSV23 ≥1 year later 1

Potential Concerns and Contraindications

• Vaccination with any pneumococcal vaccine is contraindicated in persons with a history of severe allergic reaction (e.g., anaphylaxis) to any component of the vaccine 1
• PCVs are also contraindicated in persons with a severe allergic reaction to any diphtheria toxoid-containing vaccine 1
• Common side effects include injection site reactions, fatigue, muscle pain, and headache 5

Evidence Quality and Evolution of Recommendations

The recommendation has evolved significantly over time:

• In 2019, ACIP recommended shared clinical decision-making for PCV13 followed by PPSV23 for adults ≥65 years 1
• By 2023, ACIP updated to recommend either PCV20 alone or PCV15 followed by PPSV23 for all adults ≥65 years 1
• The 2024 update added PCV21 as an option, maintaining the preference for conjugate vaccines 1

The evidence supports that conjugate vaccines provide superior immunogenicity compared to polysaccharide vaccines, particularly in older adults who received PPSV23 many years ago 6. Sequential PCV/PPSV23 vaccination has shown high effectiveness against pneumococcal community-acquired pneumonia in adults aged 65-74 years 7, supporting the current recommendation for either PCV20/PCV21 alone or PCV15 followed by PPSV23.