What is the recommended pneumococcal (pneumonia) vaccine schedule for adults over 50?

Pneumococcal Vaccination Recommendations for Adults Age ≥50

For adults over 50 years of age, a single dose of PCV20 is the recommended pneumococcal vaccination, or alternatively PCV15 followed by PPSV23 if PCV20 is not available. 1, 2

General Recommendations for Adults ≥65 Years

For Previously Unvaccinated Adults:

• Option A (Preferred): Single dose of PCV20
• Option B: Single dose of PCV15, followed by PPSV23 ≥1 year later

For Adults with Prior Vaccination:

• If previously received PPSV23 only: Administer PCV20 ≥1 year after the last PPSV23 dose
• If previously received PCV13 only: Administer PCV20 ≥1 year after PCV13 dose
• If previously received both PCV13 and PPSV23: Consider PCV20 if ≥5 years since last pneumococcal vaccine

Special Considerations by Health Status

For Immunocompetent Adults with Chronic Conditions (ages 50-64):

• Chronic heart disease, lung disease, liver disease, diabetes, alcoholism, cigarette smoking
• Option A: Single dose of PCV20
• Option B: Single dose of PCV15, followed by PPSV23 ≥1 year later

For Immunocompromised Adults:

• Includes those with chronic renal failure, asplenia, immunodeficiency, HIV, malignancy, transplant recipients
• Option A: Single dose of PCV20
• Option B: Single dose of PCV15, followed by PPSV23 after ≥8 weeks (shorter interval due to higher risk)

For Hematopoietic Stem Cell Transplant Recipients:

• Requires more intensive vaccination schedule:
  • 3 doses of PCV20, 4 weeks apart starting 3-6 months after HSCT
  • Fourth dose of PCV20 ≥6 months after third dose or ≥12 months after HSCT, whichever is later
  • If PCV20 unavailable: 3 doses of PCV15 followed by PPSV23 ≥1 year after HSCT

Important Timing Considerations

• Minimum interval between PCV15 and PPSV23:
  • Immunocompetent adults: ≥1 year
  • Immunocompromised adults: ≥8 weeks
• After previous PPSV23: Wait ≥1 year before administering PCV20 or PCV15
• For adults who received PCV7 only: Follow recommendations for unvaccinated adults

Clinical Pearls and Common Pitfalls

• Check vaccination history: Always verify previous pneumococcal vaccination status before administering new vaccines
• Avoid coadministration: PCV and PPSV23 should not be administered concurrently
• Order matters: If both vaccines are to be administered, PCV13/15/20 should be given first when possible, as prior PPSV23 can diminish immune response to subsequent PCV administration 3, 4, 5
• Revaccination benefit: A second PCV13 given about 4 years after initial vaccination can induce significantly higher antibody titers than the first dose 5
• Sequential vaccination: The V114 (15-valent PCV) followed by PPSV23 has shown comparable safety and immunogenicity to PCV13 followed by PPSV23 6

The 2023 ACIP guidelines represent a significant update from previous recommendations, with a preference for the newer conjugate vaccines (PCV15, PCV20) over the previous PCV13/PPSV23 sequential approach. This simplifies the vaccination schedule while providing broader serotype coverage.