What is the recommended pneumonia vaccination schedule for adults over their lifetime?

Pneumococcal Vaccination Schedule for Adults

All adults aged ≥65 years should receive a single dose of PCV20 (20-valent pneumococcal conjugate vaccine), which has replaced the previous two-vaccine series and simplified the vaccination schedule. 1, 2

Adults Aged ≥65 Years

Never Previously Vaccinated

• Administer a single dose of PCV20 1, 2
• This single dose provides comprehensive coverage and eliminates the need for PPSV23 in most cases 1

Previously Received PPSV23 Only

• Administer a single dose of PCV20 at least 1 year after the last PPSV23 dose 1, 2
• The 1-year interval is critical to optimize immune response 1

Previously Received PCV13 Only

• Administer a single dose of PCV20 at least 1 year after the last PCV13 dose 3
• This provides additional serotype coverage beyond the original 13 serotypes 3

Previously Received Both PCV13 and PPSV23

• Providers may choose to administer PCV20 after a ≥5 year interval since the last pneumococcal vaccine dose 1
• This is optional and based on clinical judgment 1

Adults Aged 19-64 Years with Risk Conditions

Chronic Medical Conditions

Adults with alcoholism, chronic heart disease, chronic liver disease, chronic lung disease, cigarette smoking, or diabetes mellitus should receive: 3

Option A (Preferred):

• Single dose of PCV20 3, 1

Option B (If PCV20 unavailable):

• PCV15 followed by PPSV23 at least 1 year later 3, 1

Immunocompromising Conditions

Adults with immunocompromising conditions (including CSF leaks, cochlear implants, asplenia, HIV, malignancy, immunosuppression, chronic renal failure) should receive: 3, 2

• Single dose of PCV20 1, 2
• If previously received PPSV23 only, give PCV20 at least 1 year after the last PPSV23 dose 3

Hematopoietic Stem Cell Transplant Recipients

This population requires a unique 4-dose series: 1, 2

• Three doses of PCV20, 4 weeks apart, starting 3-6 months after HSCT 1, 2
• Fourth dose of PCV20 at least 6 months after the third dose OR at least 12 months after HSCT, whichever is later 1, 2

Critical Timing Intervals

The intervals between different pneumococcal vaccines are essential for optimal immune response: 1

• PCV20 after PPSV23: Wait at least 1 year 1, 2
• PCV20 after PCV13: Wait at least 1 year 3
• PPSV23 after PCV15: Wait at least 1 year 3
• Not waiting the appropriate interval can reduce immune response 1

Important Clinical Considerations

Shared Clinical Decision-Making for PCV13

• PCV13 is no longer routinely recommended for all adults aged ≥65 years 3
• The 2019 ACIP update changed this to shared clinical decision-making for immunocompetent adults ≥65 years without CSF leak or cochlear implant 3
• This change occurred because pediatric PCV13 use created herd immunity, reducing disease burden in older adults 3

Administration Details

• PCV20 can be administered at the same visit as other age-appropriate vaccines at different anatomic sites 2
• Each 0.5-mL dose is administered intramuscularly 4
• Do not mix PCV20 with other vaccines in the same syringe 4

Common Pitfalls to Avoid

• Always check prior pneumococcal vaccination history before administering vaccines 2
• Use patient's verbal history if immunization records are unavailable—do not withhold vaccination 2
• Avoid giving PPSV23 before PCV13 in previously unvaccinated adults, as this diminishes response to subsequent PCV13 5
• Revaccination is contraindicated in persons who had severe reactions to initial doses 2

Historical Context

Prior to 2021-2023, the standard recommendation was PCV13 followed by PPSV23 for adults ≥65 years 6, 7, 8. The introduction of higher-valency conjugate vaccines (PCV15 and PCV20) has simplified the schedule, with PCV20 as a single dose now being the preferred approach 3, 1.