Who should receive pneumococcal (Streptococcus pneumoniae) vaccination?

Pneumococcal Vaccination Indications

All adults aged ≥50 years should receive pneumococcal vaccination, along with younger adults (aged 19-49 years) who have specific chronic illnesses, immunocompromising conditions, or anatomic/functional asplenia. 1, 2

Age-Based Recommendations

Adults ≥65 Years

• Universal vaccination is recommended for all adults aged 65 years and older, regardless of health status or prior vaccination history. 3, 2
• Administer either a single dose of PCV20 alone OR PCV15 followed by PPSV23 at least 1 year later. 3, 2
• If vaccination status is unknown, give one dose of vaccine without delay. 3, 2

Adults Aged 50-64 Years

• All adults aged 50-64 years should receive pneumococcal vaccination as of October 2024. 1
• This represents an expansion from previous recommendations that only covered those with risk factors in this age group. 1
• Options include PCV20, PCV21 alone, or PCV15 in series with PPSV23. 1

Adults Aged 19-49 Years

• Vaccination is indicated only for those with specific risk conditions (detailed below). 3, 2

Risk-Based Recommendations for Adults 19-64 Years

Chronic Medical Conditions

Vaccinate adults aged 19-64 years with any of the following:

• Chronic cardiovascular disease (congestive heart failure, cardiomyopathies—but NOT hypertension alone). 3, 2
• Chronic pulmonary disease (COPD, emphysema—but NOT asthma). 3, 2
• Diabetes mellitus. 3, 2
• Chronic liver disease (cirrhosis) or alcoholism. 3, 2
• Cerebrospinal fluid leaks. 3, 2
• Cigarette smoking. 2

Immunocompromising Conditions

Vaccinate all adults aged ≥19 years with immunocompromising conditions, as these patients face the highest risk for severe pneumococcal disease despite potentially reduced vaccine efficacy. 3, 2

Priority conditions include:

• HIV infection (vaccinate as soon as possible after diagnosis confirmation). 3, 2
• Functional or anatomic asplenia (including sickle cell disease or splenectomy). 3, 2
• Hematologic malignancies (leukemia, lymphoma, Hodgkin disease, multiple myeloma). 3, 2
• Generalized malignancy. 3, 2
• Chronic renal failure or nephrotic syndrome. 3, 2
• Organ or bone marrow transplantation. 3, 2
• Immunosuppressive therapy (including long-term systemic corticosteroids). 3, 2

Special Populations and Settings

• Residents of nursing homes and long-term care facilities. 3, 2
• Alaskan Natives and certain American Indian populations (due to documented increased risk). 3, 2

Critical Timing Considerations

Pre-Procedure Vaccination

• Administer pneumococcal vaccine at least 2 weeks before elective splenectomy. 3, 2
• Give vaccine at least 2 weeks before initiation of immunosuppressive therapy. 2

Post-Transplant Vaccination

• For hematopoietic stem cell transplant recipients, begin vaccination 3-6 months after transplant. 2

Avoid During Active Treatment

• Do not vaccinate during active chemotherapy or radiation therapy. 2

Important Clinical Caveats

Asplenia-Specific Warnings

Patients with asplenia must understand that vaccination does not guarantee protection against fulminant pneumococcal disease, which carries a 50-80% case-fatality rate. 3, 2

• These patients require prompt medical evaluation for any unexplained fever or signs of sepsis. 3
• Consider antimicrobial prophylaxis in addition to vaccination. 3, 2

Concurrent Vaccination

• Pneumococcal vaccine can be safely administered simultaneously with influenza vaccine (in opposite arms) without increased side effects or reduced antibody response. 3, 2

Common Pitfalls to Avoid

1. Do NOT withhold vaccination in patients with unknown vaccination history—vaccinate them. 3, 2

2. Do NOT consider asthma an indication for pneumococcal vaccination (unlike COPD, which is an indication). 3, 2

3. Do NOT delay vaccination in HIV-positive patients—vaccinate immediately upon diagnosis confirmation. 3, 2

4. Do NOT miss vaccination opportunities during routine healthcare visits, particularly in adults aged 50-64 years with risk factors. 2

5. Do NOT forget to assess vaccination status during the adolescent immunization visit at 11-12 years of age for those with risk factors. 3, 2

6. Do NOT assume recurrent upper respiratory infections (otitis media, sinusitis) are indications for pneumococcal vaccination in otherwise healthy individuals—they are not. 3