What is the recommended pneumococcal vaccine (Pneumococcal Conjugate Vaccine (PCV) and Pneumococcal Polysaccharide Vaccine (PPSV)) schedule for individuals at high risk of pneumococcal disease?

Pneumococcal Vaccination Schedule for High-Risk Individuals

For individuals at high risk of pneumococcal disease, a single dose of PCV20 is the preferred vaccination option, or alternatively, a single dose of PCV15 followed by PPSV23 at least 1 year later (or 8 weeks later for immunocompromised patients). 1

Recommended Vaccination Options

For Adults ≥65 years and Adults 19-64 years with Underlying Medical Conditions:

1. Preferred Option:

   • Single dose of PCV20 (20-valent pneumococcal conjugate vaccine)

2. Alternative Option:

   • Single dose of PCV15 (15-valent pneumococcal conjugate vaccine)
   • Followed by PPSV23 (23-valent pneumococcal polysaccharide vaccine) ≥1 year later

Special Considerations for Immunocompromised Patients:

For adults with immunocompromising conditions, the same vaccination options apply, but:

• If using PCV15, the interval between PCV15 and PPSV23 can be shortened to at least 8 weeks 1

High-Risk Groups Requiring Pneumococcal Vaccination

Immunocompromised Conditions:

• HIV infection
• Congenital or acquired immunodeficiencies
• Generalized malignancy
• Hodgkin disease, leukemia, lymphoma, multiple myeloma
• Nephrotic syndrome
• Sickle cell disease
• Solid organ transplant recipients 1

Other High-Risk Medical Conditions:

• Chronic heart disease
• Chronic lung disease
• Diabetes mellitus
• Alcoholism
• Chronic liver disease
• Cigarette smoking
• Chronic renal failure
• CSF leaks 1

Post-Transplant Vaccination Schedule

Patients who have undergone solid organ transplant or hematopoietic stem cell transplantation (HSCT) require a specialized schedule:

• 3-4 doses of PCV20 (or PCV15), 4 weeks apart
• Starting 3-6 months after transplant
• Fourth dose administered at least 6 months after the third dose or at least 12 months after transplant (whichever is later) 1

Clinical Considerations

• The 2023 ACIP recommendations simplify the pneumococcal vaccination schedule while providing broader serotype coverage through newer higher-valency conjugate vaccines (PCV15, PCV20) 1
• PCV13 has demonstrated efficacy against vaccine-type invasive pneumococcal disease (IPD) and pneumonia in adults aged ≥65 years with or without underlying chronic conditions 2
• Initial vaccination with PCV13 establishes an immune state that results in recall anti-pneumococcal responses upon subsequent vaccination with either conjugated or free polysaccharide vaccine 3
• In contrast, initial vaccination with PPSV23 results in an immune state in which subsequent PPSV23 administration yields generally lower responses compared with initial responses 3

Common Pitfalls to Avoid

• Avoid administering PPSV23 before PCV15: This sequence can diminish the response to subsequent PCV15 administration 4
• Avoid coadministration of PCV13 and PPSV23: These should not be administered simultaneously 1
• Don't delay vaccination in high-risk groups: Pneumococcal disease burden is persistent in adults with underlying chronic conditions 2
• Don't overlook the need for specialized schedules in transplant recipients: These patients require multiple doses at specific intervals 1

The current recommendations represent a significant update from previous guidelines that recommended PCV13 followed by PPSV23 for all adults 65 years and older and those at high risk of pneumococcal disease 5. The newer PCV20 vaccine provides broader serotype coverage in a single dose, simplifying the vaccination schedule while maintaining protection against pneumococcal disease.