What is the recommended administration schedule for the pneumococcal combo vaccine (Prevnar 13, PCV13) in children under 2, adults 65 and older, and individuals with certain medical conditions, such as immunocompromising conditions or chronic heart or lung disease?

Pneumococcal Vaccination Schedule

Children Under 2 Years

All children under 2 years should receive PCV13 (Prevnar 13) as a 4-dose series at ages 2,4,6, and 12-15 months. 1, 2

• This routine schedule has been the standard since 2010 when PCV13 replaced PCV7 1
• The primary series consists of doses at 2,4, and 6 months, with a booster dose at 12-15 months 2, 3
• Children who only received PCV7 remain susceptible to the six additional serotypes in PCV13 and should receive a supplemental dose 2

Adults 65 Years and Older

As of 2023, adults ≥65 years should receive either a single dose of PCV20 (preferred) OR PCV15 followed by PPSV23 at least 1 year later. 1, 4, 5

Key Changes in Recommendations

• PCV13 is no longer routinely recommended for all adults ≥65 years as of 2019 due to indirect protection from pediatric vaccination programs reducing disease burden 1
• For adults ≥65 without immunocompromising conditions, CSF leak, or cochlear implant, PCV13 may be considered through shared clinical decision-making, but is not routinely recommended 1, 6
• All adults ≥65 years should continue to receive PPSV23 1, 6

Vaccination Algorithm for Adults ≥65

If never vaccinated:

• Give PCV20 alone (preferred for simplicity) 4, 5
• Alternative: Give PCV15 followed by PPSV23 ≥1 year later 4, 5

If previously received PPSV23 before age 65:

• Give PCV20 at least 1 year after the last PPSV23 dose 4
• Then give another PPSV23 at age ≥65 if at least 5 years have passed since the previous PPSV23 6

If previously received only PCV13:

• Give PCV20 or PPSV23 at least 1 year after PCV13 4

Individuals with Immunocompromising Conditions

Adults ≥19 years with immunocompromising conditions, CSF leak, or cochlear implant require PCV13 (or newer PCV15/PCV20) followed by PPSV23 with shorter intervals. 1, 6

High-Risk Conditions Requiring Aggressive Vaccination

Immunocompromising conditions include: 4, 6, 5

• Congenital or acquired asplenia
• Sickle cell disease
• Chronic renal failure or nephrotic syndrome
• HIV infection
• Congenital or acquired immunodeficiencies
• Malignancies requiring immunosuppressive therapy
• Solid organ transplant recipients
• Iatrogenic immunosuppression

Vaccination Schedule for Immunocompromised Adults

Give PCV13/PCV15/PCV20 first, then PPSV23 at least 8 weeks later (not 1 year). 4, 6

• The shorter 8-week interval (versus 1 year for immunocompetent adults) reflects greater urgency for protection in high-risk patients 4
• A second dose of PPSV23 is recommended 5 years after the first PPSV23 dose for immunocompromised patients who received their first dose before age 65 4, 6
• If elective splenectomy or immunosuppressive therapy is planned, complete vaccination at least 2 weeks before surgery or therapy initiation 4

Adults with Chronic Medical Conditions (Non-Immunocompromising)

Adults 19-64 years with chronic heart disease, chronic lung disease, diabetes, chronic liver disease, alcoholism, or current cigarette smoking should receive pneumococcal vaccination. 5

Vaccination Schedule for Chronic Conditions

• Give either PCV20 alone OR PCV15 followed by PPSV23 ≥1 year later 5
• These patients use the standard 1-year interval (not 8 weeks) between PCV and PPSV23 since they are immunocompetent 4
• Review vaccination status again when turning 65 to determine if additional doses are needed 4

Critical Timing Intervals

Never co-administer PCV and PPSV23 on the same day. 4, 6

• Immunocompetent adults: ≥1 year between PCV and PPSV23 1, 4, 6
• Immunocompromised adults: ≥8 weeks between PCV and PPSV23 4, 6
• If PPSV23 given first: Wait ≥1 year before giving PCV 4

Important Caveats

• The 2023 guidelines now favor newer conjugate vaccines (PCV15, PCV20) over PCV13 due to broader serotype coverage 1, 4
• PPSV23 contains 11 additional serotypes not in PCV13, accounting for 32-37% of invasive pneumococcal disease in adults ≥65 4, 6
• For adults who completed PCV13 + PPSV23 series at age ≥65, this is considered a lifetime vaccination with no routine boosters recommended 4
• If vaccination history is uncertain, do not delay—use verbal history and proceed with indicated vaccination 4
• Avoid unnecessary revaccination with PPSV23 after the dose given at age ≥65; no additional PPSV23 doses are recommended for immunocompetent adults 4, 6