What is the recommended pneumonia vaccine schedule for adults 65 years and older or those with underlying health conditions in a given location?

Pneumococcal Vaccination Schedule for Adults

For Adults ≥65 Years Without Prior Vaccination

Administer a single dose of PCV20 (preferred option) or PCV21, which completes the pneumococcal vaccination series with no additional doses needed. 1, 2

• Alternatively, give PCV15 followed by PPSV23 at least 1 year later, which also completes the series. 1, 2
• No booster doses are recommended after completing this series. 2, 3
• The 2023-2024 ACIP guidelines prioritize newer conjugate vaccines (PCV15, PCV20, PCV21) over the older PPSV23-first approach due to broader serotype coverage and superior immunologic properties. 2

For Adults Aged 19-64 Years With Chronic Medical Conditions

Give a single dose of PCV20 now, which completes the series for adults with chronic conditions including heart disease, lung disease (COPD, asthma), liver disease, diabetes, alcoholism, or smoking history. 1, 3

• If previously received PPSV23 only: Give PCV20 at least 1 year after the last PPSV23 dose. 1, 3
• If previously received PCV13 only: Give PPSV23 at least 1 year after PCV13, then review vaccination status again when the patient turns 65 years old. 1
• If previously received both PCV13 and PPSV23: No vaccines are recommended at this time; review recommendations again at age 65. 1

For Immunocompromised Adults (Any Age ≥19 Years)

For immunocompromised patients, use an accelerated schedule with shorter intervals between vaccines due to higher risk of invasive pneumococcal disease. 1, 2

Option A (Preferred for Simplicity):

• Give a single dose of PCV20, which completes the series. 1, 3

Option B (If PCV20 Unavailable):

• Give PCV15 followed by PPSV23 at least 8 weeks later (not 1 year). 1, 2
• If the first PPSV23 was given before age 65, give a second PPSV23 dose at least 5 years after the first PPSV23. 1, 2, 3
• When the patient turns 65, if at least 5 years have passed since the last PPSV23, give one final PPSV23 dose. 3, 4

Immunocompromising conditions include: chronic renal failure, asplenia (congenital or acquired), sickle cell disease, HIV infection, malignancies, immunosuppressive therapy (including long-term corticosteroids), solid organ transplant, hematopoietic stem cell transplant, complement deficiencies, and nephrotic syndrome. 1, 2

For Adults With Prior PPSV23 Before Age 65

Give PCV20 or PCV15 at least 1 year after the last PPSV23 dose. 1, 3

• If PCV15 is chosen, follow with PPSV23 at least 1 year later (or ≥8 weeks if immunocompromised). 1, 2
• When the patient turns 65, if at least 5 years have passed since the last PPSV23 dose, give one final PPSV23 dose. 3, 4
• No additional PPSV23 doses are given after the dose administered at age ≥65 years. 2, 3, 4

For Adults With CSF Leaks or Cochlear Implants

Follow the same accelerated schedule as immunocompromised patients: PCV first, then PPSV23 at least 8 weeks later. 1, 2, 3

• Give a second PPSV23 dose at least 5 years after the first if given before age 65. 1, 3

Critical Timing Rules to Avoid Errors

Never coadminister pneumococcal vaccines on the same day, as this reduces immune response and wastes the vaccine. 2, 3, 4

• Wait at least 1 year between PCV and PPSV23 for immunocompetent patients. 1, 2
• Wait only 8 weeks between PCV and PPSV23 for immunocompromised patients, those with CSF leaks, or cochlear implants. 1, 2
• The shorter 8-week interval for high-risk patients reflects greater urgency for protection in those at higher risk for invasive pneumococcal disease. 2

Maximum Lifetime PPSV23 Doses

Immunocompetent adults: Maximum of 1-2 doses total (one before age 65 if indicated, one at/after age 65). 3, 4

Immunocompromised adults: Maximum of 2-3 doses total (initial dose, booster at 5 years if given before age 65, final dose at/after age 65). 2, 3, 4

• The 5-year interval for PPSV23 boosters applies only to select high-risk immunocompromised populations who received their first dose before age 65. 2, 3
• The ACIP does not recommend multiple revaccinations beyond these schedules due to uncertainty regarding clinical benefit and safety. 2

Special Considerations for Uncertain Vaccination History

If vaccination status is uncertain, do not delay vaccination—use the patient's verbal history and proceed with vaccination if indicated. 2

• Document vaccination clearly to avoid unnecessary future doses, but never withhold vaccination due to missing records. 2
• Avoid giving multiple PPSV23 boosters beyond what is recommended, as there is insufficient evidence for safety with three or more doses. 2

Common Pitfalls to Avoid

• Do not give PPSV23 first in vaccine-naïve adults ≥65 years—the current standard is PCV20/PCV21 first or PCV15 followed by PPSV23. 1, 2
• Do not confuse the 8-week interval (immunocompromised) with the 1-year interval (immunocompetent)—this is the most common scheduling error. 1, 2, 3
• Do not give unnecessary PPSV23 boosters after the dose given at age ≥65 years—this is explicitly not recommended. 2, 3, 4
• For patients who received PCV13 and PPSV23 at age ≥65 years, shared clinical decision-making may be considered to administer PCV20 or PCV21 ≥5 years after the last dose, but this is optional, not routine. 1, 2