What are the recommendations for pneumococcal (Streptococcus pneumoniae) vaccination?

Pneumococcal Vaccination Recommendations

Current Adult Recommendations (≥19 Years)

For adults aged ≥65 years and adults aged 19-64 years with certain underlying medical conditions or risk factors who have not received a pneumococcal conjugate vaccine (PCV), use either PCV20 alone OR PCV15 followed by PPSV23. 1

Specific Adult Vaccination Strategies:

• PCV20 alone: Single dose provides comprehensive coverage without need for additional PPSV23 1
• PCV15 + PPSV23 series: PCV15 followed by PPSV23 at least 1 year later (minimum 8 weeks for immunocompromised conditions) 1

High-Risk Adults Requiring Vaccination (Ages 19-64):

• Immunocompromising conditions (HIV, malignancy, immunosuppressive therapy, solid organ transplant) 1
• Functional or anatomic asplenia (including sickle cell disease) 1
• CSF leaks or cochlear implants 1
• Chronic medical conditions (heart disease, lung disease, diabetes, chronic liver disease, alcoholism, smoking) 1

Adults Previously Vaccinated:

• Started with PCV13 only: Complete series with either PCV20 alone OR ≥1 dose of PPSV23 1
• Completed PCV13 + PPSV23: Shared clinical decision-making regarding supplemental PCV20 dose for those ≥65 years 1
• Received PPSV23 only: May receive PCV15 or PCV20 (new CDC guidance) 1

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Pediatric Recommendations

All infants and children should receive routine pneumococcal conjugate vaccination starting at 2 months of age with a 4-dose series at 2,4,6, and 12-15 months. 1

Standard Infant Schedule:

• Primary series: 3 doses at 2,4, and 6 months of age 1
• Booster dose: 1 dose at 12-15 months of age 1
• This schedule provides protection during the highest-risk period, as children <2 years have incidence rates of 165-203 cases per 100,000 population 1

High-Risk Children (Ages 2-5 Years):

Children aged 24-59 months with high-risk conditions require PCV13 followed by PPSV23 at least 8 weeks later. 1

High-risk conditions include:

• Immunocompromising conditions (HIV, malignancy, immunosuppressive therapy, congenital immunodeficiency) 1
• Functional or anatomic asplenia (including sickle cell disease) 1
• CSF leaks or cochlear implants 1
• Chronic heart disease, chronic lung disease, diabetes mellitus 1

Moderate-Risk Children (Ages 24-59 Months):

Consider vaccination with priority for:

• Children aged 24-35 months 1
• Alaska Native, American Indian, and African-American children 1
• Children attending group day care centers 1

Immunocompromised Children (Ages 6-18 Years):

PCV13 should be administered to all children aged 6-18 years with immunocompromising conditions, functional or anatomic asplenia, CSF leaks, or cochlear implants, regardless of prior PCV7 or PPSV23 receipt. 1 This represents a category A recommendation, upgraded from previous permissive guidance 1.

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Catch-Up Vaccination Schedules

Children Starting Late (Previously Unvaccinated):

• Ages 7-11 months: 2 doses (8 weeks apart) plus booster at 12-15 months 1
• Ages 12-23 months: 2 doses (8 weeks apart) 1
• Ages 24-59 months (healthy): 1 dose of PCV13 2
• Ages 24-59 months (high-risk): 2 doses of PCV13 (8 weeks apart), then PPSV23 ≥8 weeks later 1

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Important Clinical Considerations

Vaccine Effectiveness:

• PCV7 demonstrated 100% efficacy against invasive disease from vaccine serotypes in initial trials, with 94% efficacy in follow-up analysis 3
• Among children receiving 3 doses before age 1 year, effectiveness was 87%; with 2 doses, effectiveness was 94% 1
• The conjugate vaccines reduce nasopharyngeal carriage, providing herd immunity, unlike polysaccharide vaccines 1

Common Pitfalls to Avoid:

• Do not use PPSV23 alone in children <2 years: They cannot mount adequate immune response to polysaccharide antigens 1, 4
• Do not forget catch-up doses: Children aged 24-59 months who received only PCV7 remain susceptible to the 6 additional serotypes in PCV13 5
• Do not delay high-risk vaccination: Children with immunocompromising conditions should receive vaccines at the earliest possible opportunity 2

Simultaneous Administration:

Pneumococcal vaccines can be administered simultaneously with other routine childhood vaccines at different injection sites 1

Antibiotic Prophylaxis:

• Daily penicillin prophylaxis (125 mg twice daily) reduces pneumococcal bacteremia by 84% in children with sickle cell disease 1
• Begin before 4 months of age; may discontinue at 5 years if no prior severe infection and adequate vaccination 1
• Also recommended for children with functional or anatomic asplenia, particularly those <2 years who cannot respond adequately to polysaccharide vaccine 1