What are the recommendations for administering Prevnar 20 (Pneumococcal conjugate vaccine)?

Prevnar 20 (PCV20) Administration Recommendations

Administer a single dose of PCV20 to all adults aged ≥65 years and to adults aged 19-64 years with chronic medical conditions or immunocompromising conditions who have not previously received a pneumococcal conjugate vaccine. 1, 2

Primary Vaccination for Vaccine-Naïve Adults

For adults who have never received any pneumococcal vaccine, give one dose of PCV20 alone—no additional pneumococcal vaccines are needed after this single dose. 2, 3, 4

Age-Based Indications

• All adults ≥65 years of age should receive PCV20 regardless of underlying medical conditions 1, 2
• Adults 19-64 years with chronic medical conditions including chronic heart disease, chronic lung disease, chronic liver disease, diabetes mellitus, alcoholism, or current cigarette smoking 2, 3
• Adults 19-64 years with immunocompromising conditions including HIV infection, congenital or acquired immunodeficiencies, iatrogenic immunosuppression, generalized malignancy, solid organ transplant, sickle cell disease, or other hemoglobinopathies 2, 3

Critical Point on Series Completion

Once PCV20 is administered, the pneumococcal vaccination series is complete for most patients—do not add PPSV23 afterward 2, 3. This is a common pitfall to avoid.

Vaccination After Prior PPSV23 Only

For adults who previously received only PPSV23, administer one dose of PCV20 at least 1 year after the last PPSV23 dose. 1, 2, 3, 4

• This recommendation applies to all age groups and risk categories 2
• The 1-year minimum interval must be observed for optimal immune response 2
• After PCV20 administration, no additional pneumococcal vaccines are needed 2, 3

Vaccination After Prior PCV13 Only

For adults who previously received only PCV13, administer one dose of PCV20 at least 1 year after the PCV13 dose. 1, 2, 3

Rationale for PCV20 After PCV13

Conjugate vaccines like PCV20 have immunologic advantages over polysaccharide vaccines, including T-cell dependent responses and immunologic memory 1. Phase III clinical trials demonstrated that PCV20 is safe and immunogenic in adults previously vaccinated with PCV13, regardless of the interval between doses (ranging from 6 months to 5 years) 1, 2.

Timing Considerations

• Standard interval: ≥1 year after PCV13 for most adults 2, 3
• Immunocompromised adults: Follow the same ≥1 year interval after PCV13 2
• The series is complete after PCV20—do not add PPSV23 2

Vaccination After Both PCV13 and PPSV23

For adults aged ≥65 years who completed the recommended vaccine series with both PCV13 and PPSV23 (with PPSV23 given at age ≥65 years), use shared clinical decision-making regarding administration of PCV20. 1, 3

If Decision Made to Vaccinate

• Administer a single dose of PCV20 ≥5 years after the last pneumococcal vaccine dose 1, 2, 3
• Note the extended 5-year interval applies only when both PCV13 and PPSV23 were previously given 2

Considerations for Shared Decision-Making

• Patient's risk for pneumococcal disease due to underlying medical conditions 1
• Time elapsed since last pneumococcal vaccination (≥5 years provides added benefit) 1
• Risk for exposure to pneumococcal serotypes contained in PCV20 1
• Adults with chronic medical conditions or immunocompromising conditions may derive greater benefit, especially if ≥5 years have elapsed since last vaccination 1

Economic Context

Cost-effectiveness models show variable results ranging from $93,000 to $970,000 per quality-adjusted life year (QALY) gained, depending on timing after prior vaccination 1. The residual disease burden from PCV13-type disease is much lower than before pediatric PCV13 implementation due to indirect effects 1.

Special Population: Immunocompromised Adults with Prior PCV13 and PPSV23

For adults aged 19-64 years with immunocompromising conditions who received both PCV13 and one dose of PPSV23, administer PCV20 ≥5 years after the last pneumococcal vaccine dose. 2, 3

• This is a firm recommendation, not shared decision-making, for this high-risk population 2
• The series is complete after PCV20 2

Special Population: Hematopoietic Stem Cell Transplant (HSCT) Recipients

For adults who received HSCT, use a 4-dose series of PCV20 starting 3-6 months after HSCT. 2

HSCT Vaccination Schedule

• First 3 doses: Given 4 weeks apart 2
• Fourth dose: At least 6 months after the third dose OR at least 12 months after HSCT, whichever is later 2

Pediatric and Adolescent Dosing

Routine Infant Series (6 Weeks Through 15 Months)

• Administer as a 4-dose series at 2,4,6, and 12-15 months of age 4
• First dose may be given as early as 6 weeks of age 4
• At least 2 months between third and fourth doses 4

Catch-Up Schedule for Previously Unvaccinated Children

• 7-11 months: 3 doses total (first 2 doses ≥4 weeks apart; third dose after first birthday, ≥2 months after second dose) 4
• 12-23 months: 2 doses ≥2 months apart 4
• 24 months through 17 years: 1 dose 4

Catch-Up for Children Previously Vaccinated with Lower Valency PCV

For individuals 15 months through 17 years previously vaccinated with one or more doses of a lower valency pneumococcal conjugate vaccine, administer a single dose of PCV20 at least 8 weeks after the last dose of the lower valency vaccine. 4

Administration Details

Preparation and Injection

• For intramuscular administration only 4
• Shake vigorously until homogeneous white suspension 4
• Do not mix with other vaccines in the same syringe 4
• Each dose is 0.5 mL 4

Contraindications

Do not administer to individuals with severe allergic reaction (e.g., anaphylaxis) to any component of PCV20 or to diphtheria toxoid 4.

Common Pitfalls to Avoid

1. Do not give PCV20 too soon: The 1-year minimum interval after PCV13 or PPSV23 must be observed for optimal response 2
2. Do not add PPSV23 after PCV20: Once PCV20 is administered, the series is complete and adding PPSV23 is unnecessary and not recommended 2, 3
3. Do not confuse timing intervals: The 5-year interval applies only when both PCV13 and PPSV23 were previously given; otherwise use the 1-year interval 2
4. Do not overlook high-risk younger adults: Adults 19-64 years with chronic conditions or immunocompromising conditions qualify for vaccination 2, 3

Clinical Impact

Pneumococcal vaccination has been associated with a 22% reduction in all-cause mortality among adults with cardiovascular disease or very high cardiovascular risk 2, 3. Current smokers have 2.8-4.1 times the risk for invasive pneumococcal disease compared with adults without underlying risk conditions 2.