What are the recommendations for administering the Pneumococcal (PCV13 or Prevnar 13) vaccine to individuals aged 65 and older, or those with chronic health conditions such as heart disease, lung disease, or diabetes, including those with weakened immune systems?

Pneumococcal Vaccination for Adults ≥65 Years and High-Risk Populations

Direct Recommendation

All adults aged ≥65 years should receive a single dose of PCV20 (preferred for simplicity) or alternatively PCV15 followed by PPSV23 at least 1 year later—this completes the series with no routine booster doses needed. 1, 2, 3

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Vaccination Strategy by Population

Healthy Adults ≥65 Years (No Prior Pneumococcal Vaccine)

Option A (Preferred): Single dose of PCV20 alone—series complete 1, 2, 3

Option B: PCV15 now, then PPSV23 ≥1 year later—series complete 1, 2, 3

• PCV20 is preferred because it provides broader serotype coverage in a single dose and eliminates the need for a second vaccine 2, 4
• No booster doses are recommended after completing either series 2, 3
• These vaccines are considered lifetime vaccinations for immunocompetent adults 2

Adults Aged 19-64 Years with Chronic Medical Conditions

Chronic conditions include: heart disease (congestive heart failure, cardiomyopathies), chronic lung disease (COPD, emphysema, asthma), chronic liver disease, diabetes mellitus, alcoholism, or cigarette smoking 1

Current recommendation: Single dose of PCV20 (preferred) or PCV15 followed by PPSV23 ≥1 year later 1, 3

• Critical caveat: Review vaccination status again when the patient turns 65 years old to determine if additional doses are needed based on prior vaccination history 1, 3
• PCV13 is no longer routinely recommended for adults with chronic conditions aged 19-64 years 1

Immunocompromised Adults (Any Age ≥19 Years)

Immunocompromising conditions include: chronic renal failure, congenital or acquired asplenia, sickle cell disease, congenital or acquired immunodeficiencies, HIV infection, malignancies, iatrogenic immunosuppression (including long-term systemic corticosteroids), leukemia, lymphoma, multiple myeloma, nephrotic syndrome, solid organ transplant 1, 2

Option A: Single dose of PCV20 alone 1, 3

Option B: PCV15 followed by PPSV23 ≥8 weeks later (not 1 year), then a second PPSV23 dose ≥5 years after the first PPSV23 if given before age 65 1, 3

• The critical distinction: Immunocompromised patients need only ≥8 weeks between PCV and PPSV23, while immunocompetent patients need ≥1 year 1, 2, 3
• The shorter 8-week interval reflects greater urgency for protection in high-risk patients 2

Adults with Cochlear Implants or CSF Leaks

Follow the same accelerated schedule as immunocompromised patients: PCV first, then PPSV23 ≥8 weeks later 1, 3

• A second PPSV23 dose is recommended ≥5 years after the first if given before age 65 1, 3

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Managing Prior Vaccination History

Previously Received PPSV23 Only

Give PCV20 or PCV15 ≥1 year after the last PPSV23 dose 1, 2, 3

• If PCV15 is chosen, follow with PPSV23 ≥1 year later (≥8 weeks if immunocompromised) 1, 3
• If patient received PPSV23 before age 65 and is now ≥65 years: give one final dose of PPSV23 if ≥5 years have passed since the last PPSV23 2, 3

Previously Received PCV13 Only

For immunocompetent adults: Give PPSV23 ≥1 year after PCV13, then review again at age 65 1

For immunocompromised adults: Give PPSV23 ≥8 weeks after PCV13, then a second PPSV23 ≥5 years later 1, 2

• Alternatively, give PCV20 ≥1 year after PCV13 to complete the series 1, 2

Previously Received Both PCV13 and PPSV23

For adults <65 years: No additional vaccines recommended until age 65 1

For adults ≥65 years who completed series: Shared clinical decision-making may be considered for PCV20 or PCV21 ≥5 years after the last pneumococcal vaccine 2

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Critical Timing Rules to Avoid Errors

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

Minimum intervals:

• Immunocompetent adults: ≥1 year between PCV and PPSV23 1, 2, 3
• Immunocompromised adults: ≥8 weeks between PCV and PPSV23 1, 2, 3

For patients requiring elective splenectomy or initiation of immunosuppressive therapy: Complete vaccination ≥2 weeks before surgery or therapy initiation 2

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Maximum Lifetime PPSV23 Doses

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

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

• No additional PPSV23 doses are given after the dose administered at age ≥65 years 1, 2, 3
• 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
• ACIP does not recommend multiple revaccinations beyond what is specified due to uncertainty regarding clinical benefit and safety 2

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Common Pitfalls and How to Avoid Them

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—there is insufficient evidence for safety with three or more doses 2

Not waiting the appropriate interval between PCV and PPSV23 reduces immune response and wastes the vaccine 3

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Evolution of Recommendations (Context)

• Prior to 2019, all adults ≥65 years received both PCV13 and PPSV23 2
• In 2019, routine PCV13 was no longer recommended for all adults ≥65 years, with shared clinical decision-making introduced 1
• The 2023-2024 ACIP guidelines introduced newer conjugate vaccines (PCV15, PCV20, PCV21) with broader serotype coverage 1, 2
• As of October 2024, ACIP expanded age-based PCV recommendations to include all adults ≥50 years 5