Should a patient over 65 with prior pneumonia vaccinations receive PCV (Pneumococcal Conjugate Vaccine)?

Pneumococcal Vaccination Recommendations for Adults Over 65 with Prior Vaccinations

For adults over 65 years with prior pneumococcal vaccinations, PCV20 (Prevnar 20) is the preferred option as a single dose, or alternatively, PCV15 followed by PPSV23 at least 1 year later. 1

Current Recommendations Based on Vaccination History

For Adults ≥65 Years with Prior Pneumococcal Vaccination:

1. Prior PPSV23 Only:

   • Preferred: Single dose of PCV20
   • Alternative: Single dose of PCV15, followed by PPSV23 ≥1 year later
   • Note: Immune responses may be diminished if PCV is given too soon after PPSV23 2

2. Prior PCV13 Only:

   • Preferred: Single dose of PCV20
   • Alternative: Single dose of PPSV23 if not previously received

3. Prior PCV13 + PPSV23:

   • Single dose of PCV20 is recommended

Rationale for Updated Recommendations

The 2019 ACIP guidelines changed the pneumococcal vaccination approach for adults ≥65 years 3. PCV13 is no longer routinely recommended for all adults in this age group due to:

• Reduced incidence of PCV13-type disease through indirect effects from pediatric PCV13 use
• Minimal population-level impact from the 2014 recommendation for universal PCV13 use in adults ≥65 years
• Cost-effectiveness concerns ($200,000-$560,000 per QALY for continued universal PCV13 use) 3

However, newer higher-valency conjugate vaccines (PCV15, PCV20) now provide broader serotype coverage and have simplified the vaccination schedule 1.

Important Clinical Considerations

• Timing between vaccines: If administering PCV15 followed by PPSV23, maintain at least a 1-year interval between doses for immunocompetent adults 1
• Avoid PPSV23 before PCV: Administering PPSV23 before PCV can diminish the immune response to subsequent PCV administration 4
• Do not coadminister PCV13 and PPSV23: These vaccines should not be given simultaneously 1
• Immunocompromised patients: Adults with immunocompromising conditions (including HIV, malignancy, transplant recipients) should receive pneumococcal vaccination regardless of age, with a more aggressive schedule 1

Efficacy Considerations

Sequential PCV13/PPSV23 vaccination has shown the highest effectiveness (80.3%) against pneumococcal community-acquired pneumonia in adults aged 65-74 years, compared to single-dose PCV13 (66.4%) or PPSV23 (18.5%) 5. The newer PCV20 provides coverage for 7 additional serotypes beyond PCV13, offering broader protection 2.

Special Populations

For adults with specific conditions, pneumococcal vaccination is particularly important:

• Immunocompromising conditions: HIV, malignancy, transplant recipients, immunodeficiencies
• Chronic medical conditions: Heart disease, lung disease, liver disease, diabetes, alcoholism
• Other risk factors: CSF leaks, cochlear implants, cigarette smoking

Common Pitfalls to Avoid

1. Waiting too long after prior vaccination: Don't delay vaccination in high-risk groups
2. Incorrect sequence: Administering PPSV23 before PCV reduces the effectiveness of the conjugate vaccine
3. Ignoring vaccination history: Prior pneumococcal vaccination type and timing impacts the current recommendation
4. Overlooking special populations: Transplant recipients require specialized schedules (3-4 doses of PCV20/PCV15)

PCV20 has demonstrated robust immune responses regardless of prior pneumococcal vaccination history and is well-tolerated in adults ≥65 years previously vaccinated with different pneumococcal vaccine regimens 2.