When should the Pneumococcal Conjugate Vaccine (PCV) 20 be administered?

When to Administer PCV20 (Pneumococcal Conjugate Vaccine 20-valent)

Administer PCV20 as a single dose to all adults aged ≥50 years who have never received a pneumococcal conjugate vaccine, as this provides the broadest serotype coverage and simplifies the vaccination schedule. 1

Age-Based Recommendations

Adults ≥65 Years

• Give one dose of PCV20 to all adults aged ≥65 years who are pneumococcal vaccine-naïve 2, 3
• This is now the standard recommendation regardless of underlying medical conditions 4

Adults 50-64 Years

• Administer PCV20 to all adults aged 50-64 years who have never received a pneumococcal conjugate vaccine 1
• This represents an expansion from the previous age threshold of 65 years 1

Adults 19-49 Years

• Give PCV20 to adults aged 19-49 years with immunocompromising conditions (HIV infection, congenital or acquired immunodeficiencies, iatrogenic immunosuppression, generalized malignancy, Hodgkin disease, leukemia, lymphoma, multiple myeloma, solid organ transplant, sickle cell disease, or other hemoglobinopathies) 4, 2
• Administer PCV20 to adults aged 19-49 years with cerebrospinal fluid leak or cochlear implant 2

Risk-Based Recommendations (Ages 19-64 Years)

Chronic Medical Conditions

Give PCV20 to adults aged 19-64 years with any of the following chronic conditions: 4

• Chronic heart disease (including congestive heart failure and cardiomyopathies) 4, 2
• Chronic lung disease (including COPD, emphysema, and asthma) 4, 2
• Chronic liver disease 4, 2
• Diabetes mellitus 4, 2
• Alcoholism 4
• Current cigarette smoking 4

Immunocompromising Conditions

Administer PCV20 to adults aged 19-64 years with: 4, 2

• HIV infection 4
• Congenital or acquired immunodeficiencies 4
• Iatrogenic immunosuppression (long-term systemic corticosteroids, radiation therapy, immunosuppressive drugs) 4
• Generalized malignancy 4
• Hodgkin disease, leukemia, lymphoma, multiple myeloma 4
• Nephrotic syndrome 4
• Sickle cell disease or other hemoglobinopathies 4, 2
• Solid organ transplant recipients 4, 2

Timing Based on Prior Pneumococcal Vaccination

No Prior Pneumococcal Vaccination

• Give one dose of PCV20 immediately 4, 2
• No additional pneumococcal vaccines are needed after PCV20 2

Prior PPSV23 Only

• Administer PCV20 at least 1 year after the last PPSV23 dose 4, 2
• This applies to all age groups and risk categories 4
• The series is complete after PCV20; no additional vaccines needed 2

Prior PCV13 Only

• Give PCV20 at least 1 year after the PCV13 dose 4, 2
• This interval applies to both immunocompetent and immunocompromised adults 2
• The vaccination series is complete after PCV20 2

Prior PCV13 and PPSV23

• For adults who received both PCV13 and PPSV23 before age 65: Administer PCV20 at least 5 years after the last pneumococcal vaccine dose 2
• For adults who received both PCV13 and PPSV23 with PPSV23 given at age ≥65: Use shared clinical decision-making regarding PCV20 administration; if given, wait at least 5 years after the last dose 2, 3

Special Population: Hematopoietic Stem Cell Transplant (HSCT)

For adults who received HSCT, use a 4-dose series of PCV20: 4

• Start 3-6 months after HSCT 4
• Give the first 3 doses 4 weeks apart 4
• Administer the fourth dose at least 6 months after the third dose OR at least 12 months after HSCT, whichever is later 4
• The clinical team should determine the precise timing based on the patient's recovery 4

Critical Timing Intervals Summary

Prior Vaccination	Minimum Interval Before PCV20	Citation
None	Give immediately	[2]
PPSV23 only	≥1 year	[4,2]
PCV13 only	≥1 year	[2]
PCV13 + PPSV23 (before age 65)	≥5 years	[2]
PCV13 + PPSV23 (at age ≥65)	≥5 years (shared decision-making)	[2,3]

Common Pitfalls to Avoid

• Do not give PCV20 before the minimum 1-year interval after PCV13 or PPSV23 2
• Do not administer PPSV23 after PCV20—the series is complete with PCV20 alone 2
• Do not confuse the 1-year interval (for single prior vaccine) with the 5-year interval (for both PCV13 and PPSV23) 2
• Do not overlook the expanded age recommendation—all adults ≥50 years now qualify, not just those ≥65 years 1
• Do not forget that immunocompromised adults aged 19-49 years need PCV20 even without chronic medical conditions 2

Rationale for PCV20

PCV20 provides broader serotype coverage than PCV13 (20 vs 13 serotypes) and offers immunologic advantages over PPSV23, including T-cell dependent responses and immunologic memory 2. Clinical trials demonstrated that PCV20 is safe and immunogenic in adults previously vaccinated with PCV13 or PPSV23, with robust opsonophagocytic antibody responses to all 20 vaccine serotypes 5, 6. The simplified single-dose schedule reduces complexity compared to sequential PCV13/PPSV23 regimens 2.