What is the recommended pneumococcal vaccination (Pneumococcal Conjugate Vaccine (PCV) / Pneumococcal Polysaccharide Vaccine (PPSV)) schedule for adults?

Pneumococcal Vaccination Recommendations for Adults

For adults aged ≥65 years, the CDC recommends a single dose of PCV20 alone or PCV15 followed by PPSV23, with PPSV23 recommended for all adults in this age group regardless of previous vaccination history. 1

Current Recommendations by Age and Risk Group

Adults ≥65 Years

• Option A (Preferred): Single dose of PCV20
• Option B: Single dose of PCV15, followed by PPSV23 ≥1 year later
• All adults ≥65 years should receive PPSV23 if they haven't already received it, or if they received it before age 65, they should receive another dose at least 5 years after the previous dose 2

Adults 19-64 Years with Immunocompromising Conditions

• Option A: Single dose of PCV20
• Option B: Single dose of PCV15, followed by PPSV23 ≥8 weeks later
• Immunocompromising conditions include:
  • Congenital or acquired asplenia
  • Sickle cell disease
  • HIV infection
  • Chronic renal failure
  • Nephrotic syndrome
  • Leukemia, lymphoma, Hodgkin disease
  • Generalized malignancy
  • Iatrogenic immunosuppression
  • Solid organ transplant
  • Multiple myeloma
  • Congenital or acquired immunodeficiencies 2, 1

Adults 19-64 Years with Certain Medical Conditions

• Option A: Single dose of PCV20
• Option B: Single dose of PCV15, followed by PPSV23 ≥1 year later
• Qualifying medical conditions include:
  • Alcoholism
  • Chronic heart disease
  • Chronic liver disease
  • Chronic lung disease
  • Cigarette smoking
  • Diabetes mellitus
  • Cochlear implant
  • CSF leak 2, 1

Special Considerations for Previously Vaccinated Adults

Adults Who Previously Received PPSV23 Only

• Administer PCV20 or PCV15 ≥1 year after the last PPSV23 dose 1

Adults Who Previously Received PCV13 Only

• Administer PCV20 ≥1 year after PCV13, or
• Administer PPSV23 ≥1 year after PCV13 (≥8 weeks for immunocompromised) 1

Adults Who Previously Received Both PCV13 and PPSV23

• No additional doses of pneumococcal vaccine are recommended 2

Timing Between Vaccines

• For immunocompetent adults: Maintain ≥1 year interval between PCV15 and PPSV23
• For immunocompromised adults: Maintain ≥8 weeks interval between PCV15 and PPSV23
• PCV13 and PPSV23 should not be coadministered 2

Recent Updates to Recommendations

The 2023 ACIP recommendations represent a significant update from the 2019 guidelines. Previously, PCV13 was recommended based on shared clinical decision-making for adults aged ≥65 years without immunocompromising conditions, CSF leaks, or cochlear implants 2. The newer recommendations prefer the higher-valency conjugate vaccines (PCV15, PCV20) for all adults ≥65 years 1.

Special Populations: Hematopoietic Stem Cell Transplant Recipients

HSCT recipients require a more intensive vaccination schedule:

• Option A: 3 doses of PCV20, 4 weeks apart starting 3-6 months after HSCT, followed by a fourth PCV20 dose ≥6 months after the third dose or ≥12 months after HSCT, whichever is later
• Option B: 3 doses of PCV15, 4 weeks apart starting 3-6 months after HSCT, followed by PPSV23 ≥12 months after HSCT if no chronic GVHD; if chronic GVHD is present, administer a fourth dose of PCV15 instead of PPSV23 2

Clinical Considerations

• The shift to newer conjugate vaccines (PCV15, PCV20) is based on their broader serotype coverage and improved immunogenicity compared to earlier vaccines
• Checking previous pneumococcal vaccination status is essential before administering new vaccines to avoid unnecessary doses
• Sequential PCV/PPSV23 vaccination has shown high effectiveness against pneumococcal community-acquired pneumonia in adults aged 65-74 years 1
• Economic analyses have influenced recommendation changes, with cost-effectiveness ratios for universal PCV13 use in adults ≥65 years estimated at $200,000 to $560,000 per QALY in 2019 2

Pitfalls to Avoid

1. Failing to check vaccination history: Always verify previous pneumococcal vaccination before administering new doses
2. Incorrect intervals between vaccines: Maintain appropriate intervals between PCV and PPSV23 based on patient's risk status
3. Coadministration issues: PCV13 and PPSV23 should not be coadministered
4. Overlooking high-risk conditions: Ensure patients with immunocompromising conditions receive the appropriate accelerated schedule
5. Confusion about newer recommendations: The 2023 recommendations prefer the newer higher-valency conjugate vaccines over previous PCV13-based recommendations

By following these updated recommendations, clinicians can provide optimal protection against pneumococcal disease for adult patients based on their age and risk factors.