What is the current pneumococcal vaccine guideline for adults, including those with chronic conditions such as heart disease, lung disease, or diabetes, and those who are immunocompromised?

Current Pneumococcal Vaccine Guidelines for Adults

All adults aged ≥50 years should receive a single dose of PCV20 (or PCV21) as the preferred pneumococcal vaccination strategy, which completes the series with no additional doses needed in most cases. 1

Age-Based Recommendations

Adults ≥65 Years (Previously Unvaccinated)

• Administer a single dose of PCV20 (preferred) or PCV21, which completes the pneumococcal vaccination series. 2, 3
• Alternative option: Give PCV15 followed by PPSV23 at least 1 year later, which also completes the series. 3
• No booster doses are recommended after completing this series. 3

Adults Aged 50-64 Years (Previously Unvaccinated)

• As of October 2024, ACIP now recommends a single dose of PCV for all PCV-naïve adults aged ≥50 years. 1
• This represents an expansion from the previous age threshold of 65 years. 1

Adults Aged 19-64 Years With Chronic Medical Conditions

Chronic medical conditions include: alcoholism, chronic heart disease (including congestive heart failure and cardiomyopathies), chronic liver disease, chronic lung disease (including COPD, emphysema, and asthma), cigarette smoking, or diabetes mellitus. 4

For vaccine-naïve patients or those who received only PCV7:

• Administer a single dose of PCV20, which completes the series. 4, 5

For patients who previously received PPSV23 only:

• Administer a single dose of PCV20 after a ≥1 year interval since the last PPSV23 dose. 4, 5

For patients who previously received PCV13 only:

• Administer a single dose of PCV20 after a ≥1 year interval since the last PCV13 dose. 4
• Alternative: Administer PPSV23 after a ≥1 year interval, then review recommendations again at age 65 years. 4

For patients who previously received both PCV13 and PPSV23:

• No vaccines are recommended at this time; review recommendations again when the patient turns 65 years. 4

Immunocompromised Adults (Any Age ≥19 Years)

Immunocompromising conditions include: chronic renal failure, congenital or acquired asplenia, congenital or acquired immunodeficiency (including B- or T-lymphocyte deficiency, complement deficiencies, and phagocytic disorders), generalized malignancy, HIV infection, Hodgkin disease, iatrogenic immunosuppression (including long-term systemic corticosteroids and radiation therapy), leukemia, lymphoma, multiple myeloma, nephrotic syndrome, sickle cell disease and other hemoglobinopathies, solid organ transplant, cochlear implants, or CSF leaks. 4

For vaccine-naïve patients or those who received only PCV7:

• Option A (preferred): Administer a single dose of PCV20, which completes the series. 4, 3, 5
• Option B: Administer PCV15 followed by PPSV23 after ≥8 weeks (not 1 year). 4, 3, 5

For patients who previously received PPSV23 only:

• Administer a single dose of PCV20 after a ≥1 year interval since the last PPSV23 dose. 4

For patients who previously received PCV13 only:

• Administer a single dose of PCV20 after a ≥1 year interval. 4
• Alternative: Administer PPSV23 after ≥8 weeks, then a second PPSV23 dose after ≥5 years. 4, 3

Critical Timing Distinction for Immunocompromised Patients

The interval between PCV and PPSV23 is ≥8 weeks for immunocompromised patients, compared to ≥1 year for immunocompetent patients with chronic conditions. 4, 3, 5 This shorter interval is essential for providing timely protection in this vulnerable population.

Special Population: Hematopoietic Stem Cell Transplant (HSCT)

For adults who received no pneumococcal vaccines after HSCT:

• Administer 3 doses of PCV20, 4 weeks apart starting 3–6 months after HSCT. 4, 2
• Administer a fourth PCV20 dose ≥6 months after the third dose of PCV20, or ≥12 months after HSCT, whichever is later. 4, 2

Alternative schedule if PCV20 unavailable:

• Administer 3 doses of PCV15, 4 weeks apart starting 3–6 months after HSCT. 4
• Follow with PPSV23 ≥12 months after HSCT if no chronic graft-versus-host disease (GVHD). 4
• If chronic GVHD is present, administer a fourth dose of PCV15 instead of PPSV23. 4

Previously Vaccinated Adults Aged ≥65 Years

For patients who received both PCV13 and PPSV23 at age ≥65 years:

• Together with the patient, providers may choose to administer a single dose of PCV20 after a ≥5 year interval since the last PCV13 or PPSV23 dose. 4, 3
• This is a shared clinical decision-making scenario, not a routine recommendation. 4

For patients who received PPSV23 before age 65:

• Give PCV20 or PCV15 at least 1 year after the last PPSV23 dose. 3
• When the patient turns 65, if at least 5 years have passed since the last PPSV23 dose, give one final dose of PPSV23. 3
• No additional PPSV23 doses are given after the dose administered at age ≥65 years. 3

Key Timing Rules to Prevent Errors

Never coadminister pneumococcal vaccines on the same day—this reduces immune response and wastes the vaccine. 3

Interval requirements:

• Immunocompetent patients: Wait ≥1 year between PCV and PPSV23. 3, 5
• Immunocompromised patients: Wait only ≥8 weeks between PCV and PPSV23. 3, 5
• Not waiting the appropriate interval reduces immune response. 2, 3, 5

Maximum lifetime PPSV23 doses:

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

Common Pitfalls to Avoid

Overlooking risk factors: A 50-64 year-old with chronic heart disease, lung disease, diabetes, or smoking history qualifies for immediate vaccination rather than waiting until age 65. 4, 5

Unnecessary revaccination: If PCV20 or PCV21 is used, the series is considered complete and no additional pneumococcal vaccination is generally needed. 3, 5

Wrong interval for immunocompromised patients: Using the 1-year interval instead of the 8-week interval delays protection in vulnerable patients. 3, 5

Forgetting to reassess at age 65: Patients vaccinated before age 65 with chronic conditions (not immunocompromising conditions) should have their pneumococcal vaccination status reviewed again at age 65. 4, 5