Pneumococcal Vaccination in the Elderly: Current Recommendations
Yes, pneumococcal vaccination recommendations for the elderly have been significantly updated, with the most recent 2024 ACIP guidelines now recommending vaccination starting at age 50 (expanded from age 65), and newer conjugate vaccines (PCV15, PCV20, and PCV21) have replaced older recommendations since 2021. 1
What Changed and When
The pneumococcal vaccination landscape for older adults has undergone major revisions:
Before 2021: ACIP recommended PPSV23 alone or PCV13 followed by PPSV23 for adults ≥65 years 2
2021: FDA licensed two new conjugate vaccines (PCV15 and PCV20) for adults ≥18 years, fundamentally changing the recommendation structure 2
2023: ACIP issued comprehensive updated guidelines recommending either PCV20 alone OR PCV15 followed by PPSV23 (≥1 year later) for all adults ≥65 years 2
October 2024: ACIP expanded age-based recommendations to include all adults ≥50 years (previously ≥65 years), representing the most recent change 1
Current Recommended Approach for Adults ≥50 Years
For vaccine-naïve patients (never received pneumococcal vaccine):
Preferred option: Single dose of PCV20 3, 4
- This is recommended for simplicity and broader serotype coverage 4
Alternative option: PCV15 followed by PPSV23 at least 1 year later 3, 4
The PCV20 single-dose approach is preferred because it provides comprehensive coverage without requiring a second vaccine dose 4.
For Patients With Prior Vaccination History
If previously received PPSV23 before age 65:
- Administer single dose of PCV20 at least 1 year after the last PPSV23 dose 3
If previously received PCV13:
- Administer single dose of PCV20 or PPSV23 at least 1 year after PCV13 3
If previously received PPSV23 at age ≥65:
- No additional PPSV23 doses are recommended 3, 4
- However, PCV15 or PCV20 can still be given if no prior PCV received 2
Special Populations Requiring Accelerated Schedules
Immunocompromised patients and those with specific conditions require shorter intervals (≥8 weeks instead of ≥1 year): 2, 3
This applies to adults with:
- Congenital or acquired immunodeficiencies 2
- HIV infection 2
- Chronic renal failure or nephrotic syndrome 2
- Malignancies requiring immunosuppressive treatment 2
- Solid organ transplant 2
- Functional or anatomic asplenia (including sickle cell disease) 2
- CSF leaks 2
- Cochlear implants 2
These high-risk patients should receive PCV first, then PPSV23 ≥8 weeks later (not ≥1 year) 5.
Why the Recommendations Changed
The shift away from universal PCV13 in 2019 and toward newer vaccines occurred because:
Indirect protection from pediatric vaccination: PCV13-type disease incidence dropped to historically low levels through herd immunity from childhood vaccination programs, with PCV13-type disease contributing only 4% of all-cause pneumonia in adults ≥65 years by 2015-2016 4
Cost-effectiveness concerns: Cost-effectiveness ratios increased dramatically from $65,000 per QALY in 2014 to $200,000-$560,000 per QALY by 2019 for universal PCV13 4
Broader serotype coverage needed: The newer vaccines (PCV15, PCV20, PCV21) cover additional serotypes beyond PCV13's 13 serotypes, addressing the 60-75% of invasive pneumococcal disease caused by the 24 serotypes included in current vaccine formulations 2
Critical Administration Rules
- Never coadminister pneumococcal vaccines on the same day 3, 4, 5
- Avoid unnecessary revaccination with PPSV23 after the dose given at age ≥65 years 3, 4
- PCV and PPSV23 must be given sequentially, never simultaneously 5
Common Pitfalls to Avoid
Do not give PPSV23 first in vaccine-naïve patients - always give PCV (PCV15, PCV20, or PCV21) before PPSV23 if using a sequential approach, as conjugate vaccines generate superior immune responses and immunologic memory compared to polysaccharide vaccines 2, 3
Do not overlook patients aged 50-64 years - the October 2024 expansion means these patients now qualify for age-based vaccination, not just risk-based vaccination 1
Do not use the old PCV13-only approach - PCV13 is no longer routinely recommended for all adults ≥65 years as of 2019, having been replaced by the newer, broader-coverage vaccines 3, 4