At what age do pneumonia immunizations typically start for adults with or without underlying medical conditions, such as chronic heart or lung disease, diabetes, or a weakened immune system?

Pneumococcal Vaccination Initiation in Adults

Pneumococcal vaccination for adults begins at age 19 years for those with chronic medical conditions (including chronic heart or lung disease, diabetes, alcoholism, or smoking) or immunocompromising conditions, and at age 50 years for all other adults regardless of health status. 1, 2

Age-Based Vaccination Thresholds

Universal Vaccination Starting at Age 50

• As of October 2024, ACIP now recommends a single dose of pneumococcal conjugate vaccine (PCV20, PCV21, or PCV15) for all adults aged ≥50 years who have never received a pneumococcal vaccine. 2
• This represents an expansion from the previous age threshold of 65 years, reflecting updated evidence on disease burden in the 50-64 age group. 2

Risk-Based Vaccination Starting at Age 19

Adults aged 19-64 years should receive pneumococcal vaccination immediately upon diagnosis with any of the following conditions: 1

Chronic Medical Conditions (Non-Immunocompromising)

• Chronic heart disease (including congestive heart failure and cardiomyopathies) 1
• Chronic lung disease (including COPD, emphysema, and asthma) 1
• Diabetes mellitus (type 1 or type 2) 1
• Chronic liver disease 1
• Alcoholism 1
• Cigarette smoking 1

For these patients, administer a single dose of PCV20 (preferred for simplicity) or PCV15 followed by PPSV23 at least 1 year later. 1, 3

Immunocompromising Conditions (Requiring More Aggressive Schedules)

• Congenital or acquired immunodeficiencies 1, 3
• HIV infection 1, 3
• Chronic renal failure or nephrotic syndrome 1, 3
• Asplenia (functional or anatomic) or sickle cell disease 1, 3
• Malignancies (leukemia, lymphoma, Hodgkin disease, multiple myeloma) 1, 3
• Solid organ transplant or hematopoietic stem cell transplant 1
• Iatrogenic immunosuppression (including long-term systemic corticosteroids) 1, 3
• Cerebrospinal fluid leak or cochlear implant 1, 3

For immunocompromised patients, use accelerated timing: PCV20 alone OR PCV15 followed by PPSV23 at least 8 weeks later (not 1 year). 1, 4, 3

Vaccination Schedule Options

Option A (Preferred for Simplicity)

• Single dose of PCV20 or PCV21 completes the series—no additional doses needed. 1, 4, 3
• This is the most straightforward approach and eliminates the need for follow-up dosing. 4, 3

Option B (Two-Dose Series)

• PCV15 followed by PPSV23: 1, 4, 3
  • For immunocompetent adults: PPSV23 given ≥1 year after PCV15 1, 3
  • For immunocompromised adults: PPSV23 given ≥8 weeks after PCV15 1, 4, 3

Critical Timing Distinctions

The interval between PCV and PPSV23 depends entirely on immune status: 4, 3

• Immunocompetent patients: Wait ≥1 year between PCV15 and PPSV23 1, 3
• Immunocompromised patients: Wait only ≥8 weeks between PCV15 and PPSV23 1, 4, 3
• Never coadminister pneumococcal vaccines on the same day—this reduces immune response. 4, 3

Special Considerations for Patients Under Age 50

For adults aged 19-49 years without risk conditions, pneumococcal vaccination is NOT routinely recommended. 2

However, vaccination should be initiated immediately if any of the chronic or immunocompromising conditions listed above develop. 1, 5

When vaccinating adults aged 19-64 years with chronic conditions, review vaccination status again when the patient turns 65 years old to determine if additional doses are needed based on prior vaccination history. 1, 4, 3

Common Pitfalls to Avoid

• Do not delay vaccination waiting for complete medical records—use verbal history and proceed with vaccination if indicated. 4
• Do not give PPSV23 first in vaccine-naïve patients—always start with a conjugate vaccine (PCV20, PCV21, or PCV15). 4, 3
• Do not use the 1-year interval for immunocompromised patients—they require the accelerated 8-week schedule. 4, 3
• Do not administer multiple PPSV23 boosters beyond what is recommended—there is insufficient evidence for safety with three or more doses. 4

Patients with Prior PPSV23 Vaccination

If a patient received PPSV23 before developing a chronic condition or before age 65: 1, 4, 3

• Administer PCV20 or PCV15 at least 1 year after the last PPSV23 dose 1, 4
• When the patient turns 65, if at least 5 years have passed since the last PPSV23 dose, give one final dose of PPSV23 4, 3
• No additional PPSV23 doses are given after the dose administered at age ≥65 years. 4, 3