What is the preferred pneumococcal conjugate vaccine (PCV), PCV 13 or PCV 23 (Pneumococcal Conjugate Vaccine), for patients, including pediatric and high-risk groups, such as the immunocompromised and elderly individuals?

Pneumococcal Vaccination: PCV13 vs PPSV23

For adults ≥65 years without immunocompromising conditions, PPSV23 is the only routinely recommended vaccine as of 2019, with PCV13 reserved for shared clinical decision-making in select high-risk exposure scenarios. For immunocompromised patients, children, and high-risk adults, both vaccines are required in sequence, with PCV13 given first. 1

Current Recommendations by Population

Healthy Adults ≥65 Years

• All adults ≥65 years should receive PPSV23 as the standard recommendation. 1, 2
• PCV13 is no longer routinely recommended for this population since 2019, when ACIP removed the universal recommendation due to successful indirect protection from pediatric PCV13 vaccination programs. 1
• PCV13 may be considered through shared clinical decision-making for adults ≥65 years in specific high-exposure scenarios: nursing home residents, those in areas with low pediatric PCV13 uptake, or travelers to regions without pediatric PCV13 programs. 1
• If PCV13 is given, it must be administered at least 1 year before PPSV23. 1

Important caveat: The 2019 guideline change reflects the dramatic success of pediatric PCV13 vaccination in reducing adult disease through herd immunity—PCV13-type disease burden dropped substantially, making routine adult vaccination less cost-effective at the population level. 1 However, individual patients may still benefit, particularly those with chronic conditions (heart disease, lung disease, diabetes, smoking history) who have higher residual disease rates. 1

Immunocompromised Adults and High-Risk Groups

• Both PCV13 and PPSV23 are required in sequence for adults ≥19 years with immunocompromising conditions, CSF leaks, or cochlear implants. 1, 2
• Give PCV13 first, followed by PPSV23 at least 8 weeks later (not 1 year) for immunocompromised patients. 3, 2
• Immunocompromising conditions include: chronic renal failure, nephrotic syndrome, HIV infection, malignancies, immunosuppressive therapy, functional or anatomic asplenia, sickle cell disease, transplant recipients, and complement deficiencies. 3, 2
• A second dose of PPSV23 is recommended 5 years after the first PPSV23 dose for immunocompromised adults. 3

Critical distinction: The shorter 8-week interval (versus 1 year for immunocompetent adults) reflects the urgent need for protection in patients at dramatically higher risk—for example, children with hematologic malignancies have 822 times the risk of PCV13-type invasive disease compared to healthy children. 1

Children and Adolescents

• PCV13 is the primary vaccine for all children aged 2-59 months as part of the routine immunization schedule (doses at 2,4,6, and 12-15 months). 1, 4
• For children aged 6-18 years with immunocompromising conditions, functional/anatomic asplenia, CSF leaks, or cochlear implants: give PCV13 first, then PPSV23 at least 8 weeks after completing all PCV13 doses. 1
• Among immunocompromised children aged 6-18 years, 49% of invasive disease is caused by PCV13 serotypes and an additional 23% by PPSV23-only serotypes, demonstrating the need for both vaccines. 1

Key Differences Between PCV13 and PPSV23

Immunologic Mechanisms

• PCV13 is a conjugate vaccine that stimulates T-cell dependent immunity, creates immunologic memory, and provides mucosal immunity that reduces nasopharyngeal carriage and transmission. 5
• PPSV23 is a polysaccharide vaccine that provides T-cell independent immunity without immunologic memory and has limited efficacy in immunocompromised individuals. 5
• PCV13 demonstrated 75% efficacy against PCV13-type invasive disease and 45% efficacy against noninvasive PCV13-type pneumonia in the landmark CAPiTA trial. 1, 6

Serotype Coverage

• PCV13 covers 13 serotypes with superior immunogenicity and herd protection effects. 6
• PPSV23 covers 23 serotypes, including 12 in common with PCV13 plus 11 additional serotypes that account for 32-37% of invasive disease in adults ≥65 years. 1, 2
• This explains why both vaccines are needed for high-risk patients—PCV13 provides better immunity to its 13 serotypes, while PPSV23 adds coverage for 11 additional serotypes. 2

Practical Implementation Algorithm

For Previously Unvaccinated Adults ≥65 Years Without High-Risk Conditions:

1. Give PPSV23 as a single dose (standard recommendation). 1
2. Consider PCV13 through shared decision-making only if: nursing home resident, low pediatric vaccination area, or frequent travel to areas without pediatric PCV13 programs. 1
3. If PCV13 is given, administer it first, then PPSV23 at least 1 year later. 1

For Adults ≥19 Years With Immunocompromising Conditions:

1. Give PCV13 first. 2
2. Give PPSV23 at least 8 weeks after PCV13. 3, 2
3. Give a second PPSV23 dose 5 years after the first PPSV23. 3
4. If elective splenectomy or immunosuppressive therapy is planned, complete vaccination at least 2 weeks before the procedure. 3

For Adults Who Received PPSV23 Before Age 65:

1. Give one additional dose of PPSV23 at age ≥65 years, at least 5 years after the previous dose. 1, 2
2. No further PPSV23 doses are needed after the dose given at age ≥65 years. 3

Common Pitfalls to Avoid

• Do not co-administer PCV13 and PPSV23 on the same day—they must be given separately with appropriate intervals. 1, 7, 2
• Do not give PPSV23 before PCV13 in vaccine-naive patients requiring both vaccines—PCV13 must come first for optimal immune priming. 1, 2
• Do not use the 1-year interval for immunocompromised patients—they require the shorter 8-week interval between PCV13 and PPSV23. 3, 2
• Do not give multiple PPSV23 boosters beyond recommendations—there is insufficient evidence for safety with three or more doses. 3
• Do not delay vaccination waiting for complete medical records—use verbal history and proceed with indicated vaccination. 3

Safety Considerations

• Both vaccines have similar safety profiles with comparable rates of severe adverse events. 1
• Common PCV13 reactions include injection site pain, redness, swelling, arm movement limitation, fatigue, headache, chills, decreased appetite, muscle pain, and joint pain. 1
• Influenza and pneumococcal vaccines can be safely co-administered at the same visit in different anatomic sites (e.g., one in each deltoid). 7