What pneumococcal vaccine (Pneumococcal Conjugate Vaccine (PCV) or Pneumococcal Polysaccharide Vaccine (PPSV)) is recommended for patients with certain health conditions living in the state?

Pneumococcal Vaccination for Adults: State-Independent Recommendations

All adults aged ≥50 years should receive a single dose of PCV20 (20-valent pneumococcal conjugate vaccine) as the preferred option, regardless of which state they live in, as pneumococcal vaccination recommendations are federally standardized and do not vary by geographic location. 1

Current ACIP Recommendations (2024)

The Advisory Committee on Immunization Practices (ACIP) recently expanded age-based recommendations in October 2024, making pneumococcal vaccination simpler and more comprehensive: 1

For Adults Aged ≥50 Years (Never Previously Vaccinated)

Primary recommendation: Single dose of PCV20 or PCV21 2, 1

Alternative option: PCV15 followed by PPSV23 at least 1 year later 2, 3

• PCV20 is preferred for simplicity - it provides broader serotype coverage in a single dose and eliminates the need for follow-up vaccination 2, 3
• The 2024 expansion to age 50+ represents a significant shift from the previous age 65+ threshold, recognizing substantial disease burden in younger adults with chronic conditions 1

For Adults Aged 19-49 Years with Risk Conditions

PCV vaccination is recommended only for those with specific high-risk conditions: 1

Immunocompromising conditions requiring PCV: 2, 4

• Chronic renal failure or nephrotic syndrome
• Immunodeficiency (congenital or acquired)
• Iatrogenic immunosuppression (chemotherapy, radiation)
• Generalized malignancy
• HIV infection
• Hodgkin disease, leukemia, lymphoma, multiple myeloma
• Solid organ transplants
• Asplenia (congenital or acquired) or sickle cell disease
• CSF leaks or cochlear implants

Chronic medical conditions (ages 19-64): 5

• Chronic heart disease (including heart failure, cardiomyopathies)
• Chronic lung disease (COPD, emphysema, asthma)
• Chronic liver disease
• Diabetes mellitus
• Alcoholism
• Cigarette smoking

Vaccination Schedule Based on Prior History

Never Vaccinated Before

• Give PCV20 as a single dose (preferred) 2, 3
• Alternative: PCV15 now, then PPSV23 ≥1 year later 2

Previously Received PPSV23 Only

• Give PCV20 or PCV15 at least 1 year after the last PPSV23 dose 2, 4
• If PCV15 is chosen, no additional PPSV23 is needed if the patient already received PPSV23 at age ≥65 years 2

Previously Received PCV13 Only

• For immunocompetent adults aged ≥65: Give PCV20 at least 1 year after PCV13 5, 2
• For immunocompromised adults <65: Give PPSV23 ≥8 weeks after PCV13, then consider PCV20 ≥5 years later 2

Previously Received Both PCV13 and PPSV23

• For adults <65 years: No additional vaccines needed until age 65, then reassess 5
• For adults ≥65 years: Shared clinical decision-making may support giving PCV20 ≥5 years after last pneumococcal vaccine 2

Special Timing Rules for High-Risk Patients

Immunocompromised patients require accelerated schedules: 2, 4

• PCV followed by PPSV23 with only ≥8 weeks interval (not the standard ≥1 year) 2, 4
• Second PPSV23 dose ≥5 years after first PPSV23 for ongoing immunocompromise 2
• This applies to patients with asplenia, sickle cell disease, chronic renal failure, HIV, malignancies, and other immunodeficiencies 2, 4

Patients with CSF leaks or cochlear implants follow the same accelerated schedule as immunocompromised patients 4, 3

Critical Administration Rules

• Never coadminister pneumococcal vaccines on the same day 2, 3
• PPSV23 and ZOSTAVAX (zoster vaccine) should ideally be separated by ≥4 weeks due to reduced VZV antibody response when given concomitantly 6
• Adults who received PPSV23 at age ≥65 years need only ONE lifetime dose - no boosters 2, 4

Why Recommendations Changed in 2019 and 2024

The 2019 shift away from universal PCV13: 5, 3

• PCV13-type disease incidence dropped dramatically due to indirect effects from pediatric PCV13 vaccination (herd immunity) 5
• By 2015-2016, PCV13-type disease contributed only 4% of all-cause pneumonia in adults ≥65 years 3
• Cost-effectiveness ratios increased from $65,000 per QALY in 2014 to $200,000-$560,000 per QALY by 2019 3
• ACIP moved to "shared clinical decision-making" for PCV13 in immunocompetent adults ≥65 years 5

The 2024 expansion to age 50+ and introduction of PCV20/PCV21: 1

• Newer conjugate vaccines (PCV20, PCV21) provide broader serotype coverage than PCV13 2, 1
• Substantial pneumococcal disease burden exists in adults aged 50-64 years, particularly those with chronic conditions 1
• Simplification of recommendations improves implementation and uptake 1

Common Pitfalls to Avoid

Do not give unnecessary PPSV23 boosters: Adults who received PPSV23 at age ≥65 years should receive only ONE dose - additional boosters are not recommended and may increase local adverse reactions 2, 4, 6

Do not use the old PCV13 recommendations: PCV13 is no longer routinely recommended for all adults ≥65 years as of 2019 - use PCV20/PCV21 or PCV15 instead 2, 3, 1

Do not forget the 1-year interval: For immunocompetent adults, maintain ≥1 year between PPSV23 and PCV (in either direction) 2, 4

Do not confuse immunocompromised timing: These patients need only ≥8 weeks between PCV and PPSV23, not 1 year 2, 4

Geographic Considerations

State of residence does NOT affect pneumococcal vaccine recommendations - these are federal ACIP guidelines that apply uniformly across all U.S. states. 5, 1

However, certain populations may benefit more from PCV vaccination: 5

• Residents of nursing homes or long-term care facilities (higher exposure risk) 5
• Residents in settings with low pediatric PCV13 uptake (less herd immunity) 5
• Travelers to settings without pediatric PCV programs 5

These considerations are based on exposure risk, not geographic location per se, and providers may consider offering PCV more proactively to these populations. 5