Pneumococcal Vaccination for Adults ≥65 Years: PCV20 vs PPSV23
For vaccine-naïve adults aged 65 and older, a single dose of PCV20 is the preferred choice over PPSV23 because it provides superior immunologic protection through T-cell dependent responses and memory B-cell formation, while offering broader serotype coverage without requiring additional doses. 1, 2, 3
Primary Recommendation for Vaccine-Naïve Adults ≥65
The 2023 ACIP guidelines recommend either a single dose of PCV20 alone OR PCV15 followed by PPSV23 for all adults aged ≥65 years who have not previously received pneumococcal vaccination. 1, 4
PCV20 is the preferred single-dose option because it completes the vaccination series without requiring any additional pneumococcal vaccines. 2, 3
Conjugate vaccines like PCV20 induce T-cell dependent immune responses that create memory B-cells, providing more durable and robust protection compared to the polysaccharide vaccine PPSV23. 1, 2, 3
PCV20 covers 20 serotypes (including all 13 serotypes in PCV13 plus 7 additional serotypes), while PPSV23 covers 23 serotypes but lacks the immunologic advantages of conjugate vaccines. 1, 5
Key Immunologic Advantages of PCV20
Phase III clinical trials demonstrated that PCV20 is safe and immunogenic in adults ≥65 years, with robust opsonophagocytic antibody responses to all 20 vaccine serotypes. 6, 7
The immunologic superiority of conjugate vaccines over polysaccharide vaccines is well-established, with PCVs generating stronger and longer-lasting immune memory. 1, 2
PCV20 provides protection against the most common serotypes causing invasive pneumococcal disease and community-acquired pneumonia in older adults. 5
Clinical Evidence Supporting PCV20
Studies in adults ≥60 years across multiple countries (US, Sweden, Japan, South Korea, Taiwan) showed PCV20 was noninferior to PCV13 for matched serotypes and to PPSV23 for additional serotypes, with similar safety profiles. 6, 8, 7
The safety and tolerability of PCV20 were comparable to PCV13, with similar rates of local reactions, systemic events, and adverse events. 6, 8, 7
No safety concerns were identified in large phase 3 trials, and serious adverse event rates were low across all age groups. 6, 7
Special Considerations for Previously Vaccinated Adults
If Previously Received PCV13 Only:
- Complete the series with either a single dose of PCV20 (≥1 year after PCV13) OR PPSV23 (≥1 year after PCV13). 1, 2
- PCV20 is preferred because it provides broader serotype coverage and completes the series without requiring additional vaccines. 2, 3
- For immunocompromised patients, the interval can be shortened to ≥8 weeks. 1, 2
If Previously Received PPSV23 Only:
- Administer a single dose of PCV20 ≥1 year after the last PPSV23 dose, with no need for additional PPSV23. 3
If Previously Received Both PCV13 and PPSV23:
- Shared clinical decision-making is recommended regarding an additional dose of PCV20 ≥5 years after the last pneumococcal vaccine. 1, 9
- Consider PCV20 for patients with multiple chronic medical conditions, immunocompromising conditions, or ≥5 years since last vaccination. 1, 9
- Economic models show variable cost-effectiveness ($93,000 to $970,000 per QALY gained), so individualized risk assessment is important. 1, 9
Practical Algorithm for Decision-Making
For vaccine-naïve adults ≥65:
For adults with prior PCV13 only:
For adults with prior PPSV23 only:
- Give PCV20 ≥1 year later → Series complete 3
For adults with both PCV13 and PPSV23:
- If ≥5 years since last dose AND high-risk features (multiple comorbidities, immunocompromised, age >70) → Consider PCV20 1, 9
- Otherwise → Series already complete, no additional vaccination needed 9, 3
Common Pitfalls to Avoid
Do not administer PPSV23 after PCV20—it provides no additional benefit and the series is complete with PCV20 alone. 3
Do not revaccinate if less than 5 years have elapsed since the last pneumococcal vaccine in adults who have completed their series. 1, 9
Do not overlook the superior immunologic properties of conjugate vaccines when choosing between PCV20 and PPSV23 for completing a vaccination series. 1, 2
For high-risk patients (immunocompromised, CSF leak, cochlear implant), remember the accelerated schedule allows ≥8 weeks between doses rather than ≥1 year. 1, 2