What are the guidelines for pneumococcal vaccination in individuals at risk for pneumococcal disease, including those with chronic medical conditions, immunocompromising conditions, and varying age groups?

Pneumococcal Vaccination Guidelines for Adults

Healthy Adults Aged ≥50 Years Without Prior Vaccination

Administer a single dose of PCV20 (preferred) or PCV21 at age ≥50 years, which completes the series with no additional doses needed. 1, 2, 3

• As of October 2024, ACIP expanded age-based PCV recommendations to include all adults aged ≥50 years (previously ≥65 years), reflecting increased pneumococcal disease burden in the 50-64 age group 3
• Alternative option: Give PCV15 followed by PPSV23 at least 1 year later, which also completes the series 1, 2
• PCV20 is preferred for simplicity (single dose) and broader serotype coverage compared to the two-dose PCV15/PPSV23 series 2, 4
• No booster doses are recommended after completing this series—this is a lifetime vaccination 2, 5

Adults Aged 19-64 Years With Chronic Medical Conditions

Give a single dose of PCV20 now, which completes the series for adults with chronic conditions including heart disease, lung disease (COPD, asthma), liver disease, diabetes, alcoholism, or smoking history. 1, 2

Vaccination Schedule Based on Prior History:

• Never vaccinated or PCV7 only: Administer PCV20 alone OR PCV15 followed by PPSV23 ≥1 year later 1, 2
• Previously received PPSV23 only: Give PCV20 at least 1 year after the last PPSV23 dose 1, 2, 5
• Previously received PCV13 only: Give PCV20 at least 1 year after PCV13, which completes the series 1, 2
• Previously received both PCV13 and PPSV23: No additional vaccines needed until age 65, then review recommendations 1, 5

Chronic Conditions Requiring Vaccination:

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

Critical timing rule: Review vaccination status again when the patient turns 65 years old to determine if additional doses are needed based on updated guidelines and prior vaccination history 1, 2

Immunocompromised Adults (Any Age ≥19 Years)

For immunocompromised patients, give PCV20 alone (Option A, preferred) OR PCV15 followed by PPSV23 at least 8 weeks later (Option B), with a second PPSV23 dose at least 5 years after the first PPSV23 if given before age 65. 1, 2

Immunocompromising Conditions Requiring Vaccination:

• Chronic renal failure or nephrotic syndrome 1
• Congenital or acquired asplenia (functional or anatomic) 1
• Sickle cell disease or other hemoglobinopathies 1
• Congenital or acquired immunodeficiencies (B-cell/T-cell deficiency, complement deficiencies particularly C1-C4, phagocytic disorders excluding chronic granulomatous disease) 1
• HIV infection 1
• Generalized malignancy, leukemia, lymphoma, Hodgkin disease, multiple myeloma 1
• Iatrogenic immunosuppression (long-term systemic corticosteroids, radiation therapy, immunosuppressive drugs) 1
• Solid organ transplant 1

Critical Distinction in Timing:

The interval between PCV and PPSV23 is ≥8 weeks for immunocompromised patients versus ≥1 year for immunocompetent patients—this shorter interval reflects greater urgency for protection in high-risk populations. 1, 2, 6

Vaccination Schedule for Immunocompromised Based on Prior History:

• Never vaccinated or PCV7 only: PCV20 alone OR PCV15 followed by PPSV23 ≥8 weeks later 1
• Previously received PPSV23 only: Give PCV20 or PCV15 at least 1 year after last PPSV23 dose 1
• Previously received PCV13 only: Give PCV20 ≥1 year after PCV13 OR give PPSV23 ≥8 weeks after PCV13, then second PPSV23 ≥5 years later 1

For immunocompromised patients who received their first PPSV23 before age 65, give a second PPSV23 dose at least 5 years after the first, then a final PPSV23 at age ≥65 years if at least 5 years have elapsed since the previous dose. 1, 2, 5

Special High-Risk Conditions: Cochlear Implants or CSF Leaks

Follow the same accelerated schedule as immunocompromised patients: PCV first, then PPSV23 at least 8 weeks later, with a second PPSV23 dose at least 5 years after the first if given before age 65. 1, 2, 4

• These conditions carry similar risk for invasive pneumococcal disease as immunocompromising conditions 1
• The 8-week interval (not 1 year) applies to these patients 2, 4

Adults Who Previously Received PPSV23 Before Age 65

Give PCV20 or PCV15 at least 1 year after the last PPSV23 dose. 2, 5

• If PCV15 is chosen, follow with PPSV23 at least 1 year later (≥8 weeks if immunocompromised) 2, 5
• When the patient turns 65, if at least 5 years have passed since the last PPSV23 dose, give one final dose of PPSV23 2, 5
• No additional PPSV23 doses are given after the dose administered at age ≥65 years—this is the final pneumococcal vaccine 1, 2, 5

Critical Timing Rules to Avoid Errors

Never coadminister pneumococcal vaccines on the same day—this reduces immune response and wastes the vaccine. 2, 5, 4

Minimum Intervals Between Vaccines:

• Immunocompetent adults: Wait at least 1 year between PCV and PPSV23 1, 2, 5, 6
• Immunocompromised adults: Wait at least 8 weeks between PCV and PPSV23 1, 2, 6
• PPSV23 boosters (immunocompromised only): Wait at least 5 years between PPSV23 doses 1, 2, 5
• PCV20 after prior PCV13: Wait at least 1 year 1
• Any PCV after prior PPSV23: Wait at least 1 year 1, 2

Not waiting the appropriate interval reduces immune response—do not shorten these intervals except as specifically recommended for immunocompromised patients. 2, 6

Maximum Lifetime PPSV23 Doses

Immunocompetent Adults:

• Maximum 1-2 doses total: One before age 65 if indicated for chronic conditions, one at/after age 65 2, 5

Immunocompromised Adults:

• Maximum 2-3 doses total: Initial dose, booster at 5 years if given before age 65, final dose at/after age 65 1, 2, 5

The 5-year interval for PPSV23 boosters applies only to immunocompromised populations who received their first dose before age 65—do not give multiple PPSV23 boosters beyond what is recommended due to insufficient evidence for safety with three or more doses. 2, 5

Common Pitfalls and How to Avoid Them

Vaccination Status Unknown:

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 2
• Never withhold vaccination due to missing records 2
• Avoid delaying vaccination waiting for complete medical records 2

Patients Requiring Elective Splenectomy or Starting Immunosuppressive Therapy:

Complete vaccination at least 2 weeks before surgery or therapy initiation to ensure adequate immune response. 5

Concomitant Administration with Other Vaccines:

• PPSV23 can be given with other vaccines (except pneumococcal vaccines) but should be administered at different injection sites 7
• When PPSV23 and ZOSTAVAX are given concomitantly, VZV antibody levels are significantly lower than with sequential administration (GMT ratio 0.70) 7

Avoiding Unnecessary Revaccination:

Do not give additional PPSV23 doses after the dose administered at age ≥65 years—no routine boosters are recommended after completing the series. 2, 5, 4

• Avoid giving multiple PPSV23 boosters beyond recommendations due to insufficient evidence for safety with three or more doses 2
• For adults who completed PCV13 and PPSV23 series at age ≥65 years, shared clinical decision-making may be considered for PCV20 or PCV21 ≥5 years after last dose, but this is not routinely recommended 5