What are the pneumococcal vaccination guidelines for individuals with high risk factors, such as older adults, young children, and those with chronic medical conditions like heart disease, lung disease, or diabetes?

Pneumococcal Vaccination Guidelines

Primary Recommendation

All adults aged ≥65 years and adults aged 19-64 years with chronic medical conditions (heart disease, lung disease, diabetes) or other risk factors should receive pneumococcal vaccination with either a single dose of PCV20 alone OR PCV15 followed by PPSV23 at least 1 year later. 1

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Age-Based Recommendations

Adults ≥65 Years (All Individuals)

• Administer one dose of PCV20 alone (preferred single-dose option) 1, 2, 3
• Alternative: PCV15 followed by PPSV23 ≥1 year later 1
• No additional pneumococcal vaccines needed after PCV20 completion 2, 3

Adults 19-64 Years with Risk Factors

Chronic Medical Conditions requiring vaccination: 1

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

Immunocompromising conditions requiring vaccination: 1

• HIV infection 1, 2
• Congenital or acquired immunodeficiencies 1
• Iatrogenic immunosuppression (including long-term systemic corticosteroids, radiation therapy) 1
• Generalized malignancy 1
• Hodgkin disease, leukemia, lymphoma, multiple myeloma 1
• Solid organ transplant 1, 2
• Chronic renal failure, nephrotic syndrome 1
• Sickle cell disease or other hemoglobinopathies 1, 2
• Cerebrospinal fluid leak 1
• Cochlear implant 1

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Vaccination Schedule by Prior History

Never Vaccinated or Unknown History

• Administer PCV20 as single dose (completes series) 1, 3
• Alternative: PCV15 now, then PPSV23 ≥1 year later 1

Previously Received PPSV23 Only

• Administer PCV20 ≥1 year after last PPSV23 dose 2, 3
• This completes the pneumococcal vaccination series 2, 3

Previously Received PCV13 Only

• Administer PCV20 ≥1 year after PCV13 dose 2, 3
• Series is complete after PCV20 administration 2, 3

Previously Received Both PCV13 and PPSV23

• Shared clinical decision-making regarding PCV20 administration 1
• If administered, give PCV20 ≥5 years after last pneumococcal vaccine dose 1, 2
• Higher benefit expected in: 1
  • Persons with immunocompromising conditions
  • Persons with multiple chronic medical conditions
  • Persons with CSF leak or cochlear implant
  • Time elapsed ≥5 years since last dose

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Special Timing Considerations

Immunocompromising Conditions

• Minimum interval between PCV15 and PPSV23 can be shortened to ≥8 weeks (instead of standard ≥1 year) 1, 2
• This applies to adults with: 1
  • Immunocompromising conditions
  • CSF leak
  • Cochlear implant

Hematopoietic Stem Cell Transplant (HSCT)

• Special 4-dose PCV20 series: 2, 3
  • Start 3-6 months after HSCT
  • First 3 doses: 4 weeks apart
  • Fourth dose: ≥6 months after third dose OR ≥12 months after HSCT (whichever is later)

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Clinical Rationale for High-Risk Groups

Chronic Heart Disease

• 3.3 times increased odds for community-acquired pneumonia (CAP) 1
• 9.9 times increased odds for invasive pneumococcal disease (IPD) 1
• 22% reduction in all-cause mortality with pneumococcal vaccination 1

Chronic Lung Disease (COPD)

• 18 times increased risk for CAP compared to those without COPD 1
• Asthma now recognized as independent risk factor for IPD 1

Diabetes Mellitus

• 1.4 times increased risk for CAP 1
• 1.4-5.9 times increased risk for IPD 1
• Relative risk highest in younger adults with diabetes 1

Cigarette Smoking

• 2.8-4.1 times increased risk for IPD compared to adults without risk conditions 1, 2
• Risk increases with pack-years 1

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Critical Implementation Points

PCV20 Advantages

• Single-dose regimen simplifies vaccination schedule 2, 3
• Broader serotype coverage (20 serotypes vs 13 in PCV13) 1, 2
• No additional vaccines needed after completion 2, 3
• Conjugate vaccine provides superior immunologic response with T-cell dependent immunity and immunologic memory 2

Common Pitfalls to Avoid

• Do NOT administer PCV20 before minimum intervals are met (≥1 year after PPSV23 or PCV13; ≥5 years if both previously given) 2, 3
• Do NOT add PPSV23 after PCV20 - the series is complete with PCV20 alone 2, 3
• Do NOT repeat doses at age ≥65 if already given at age <65 for risk-based indications 1
• Do NOT confuse the ≥1 year standard interval with the ≥5 year interval required when both PCV13 and PPSV23 were previously given 2, 3

Vaccine Coverage Gaps

• Only 23% of adults aged 19-64 years at increased risk had ever received pneumococcal vaccine as of 2018 1
• Hispanic persons consistently have lower coverage than other racial/ethnic groups 1
• Vaccination rates vary by condition: HIV/AIDS patients (48%) vs alcohol dependence (6%) 1

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Pediatric Considerations

Children <2 Years

• PPSV23 (Pneumovax 23) is NOT approved for children <2 years of age 4
• Children in this age group do not develop effective immune response to polysaccharide vaccines 4

Children ≥2 Years with Risk Factors

• ACIP has specific recommendations for children ≥2 years with increased risk for pneumococcal disease who previously received pneumococcal vaccines 4
• Sickle cell disease, asplenia, or post-splenectomy patients aged 2-25 years experienced significantly less bacteremic pneumococcal disease with vaccination 4