Do children who have already received the pneumococcal conjugate (PCV20) vaccine need to receive the pneumococcal polysaccharide (PPSV23) vaccine?

Pneumococcal Vaccination in Children: PCV20 and PPSV23

Healthy children who receive PCV20 do not need PPSV23, but children with high-risk medical conditions (immunocompromising conditions, asplenia, CSF leaks, cochlear implants) aged ≥2 years should receive PPSV23 at least 8 weeks after completing their PCV series to provide broader serotype coverage.

For Healthy Children

• Healthy children require only the pneumococcal conjugate vaccine series (PCV13, PCV15, or PCV20) and do not need PPSV23. 1
• The standard infant series consists of 4 doses at 2,4,6, and 12-15 months of age. 2
• For healthy children 24-59 months who are unvaccinated or incompletely vaccinated, only 1 dose of conjugate vaccine is needed. 2

For High-Risk Children (Key Decision Point)

High-risk conditions requiring both PCV and PPSV23 include: 1, 3

• Functional or anatomic asplenia (including sickle cell disease)
• Immunocompromising conditions (HIV, malignancy, immunosuppressive therapy, solid organ transplant)
• Cochlear implants
• Cerebrospinal fluid (CSF) leaks
• Chronic heart disease, chronic lung disease, diabetes mellitus, chronic renal failure, nephrotic syndrome, chronic liver disease

Sequential Vaccination Algorithm for High-Risk Children

Step 1: Complete PCV series first 1, 3

• Children 24-71 months with high-risk conditions who received <3 doses before age 24 months need 2 doses of PCV13 (or PCV20) spaced 8 weeks apart. 3, 4
• Children who completed a 4-dose PCV7 series should receive 1 supplemental dose of PCV13 or PCV20. 4

Step 2: Administer PPSV23 at least 8 weeks after the final PCV dose 1, 3

• All high-risk children aged ≥2 years should receive PPSV23 after completing their PCV series. 3
• The minimum interval between the most recent PCV dose and PPSV23 is 8 weeks. 3, 4

Rationale for Sequential Vaccination in High-Risk Children

• Conjugate vaccines must be given first because they provide superior immunologic priming, induce immunologic memory, reduce nasopharyngeal carriage, and are more effective against invasive disease. 1
• PPSV23 should never be used alone in children because it lacks these advantages. 1
• PPSV23 provides coverage for additional serotypes beyond those in PCV13/PCV20, which is critical for high-risk children who face infections from a broader range of pneumococcal serotypes. 1

Critical Pitfall to Avoid

Never give PPSV23 before PCV in vaccine-naive children, as this can impair the subsequent immune response to PCV. 3

• If PPSV23 was inadvertently given first, wait at least 8 weeks before administering PCV. 4
• Studies have raised concerns about hyporesponsiveness (lower antibody response) when polysaccharide vaccines are given before conjugate vaccines, though the clinical significance remains uncertain. 1

Special Consideration for PCV20

• According to the most recent CDC guidance for adults with cancer, those receiving PCV20 do not need additional PPSV23 because PCV20 already covers 20 serotypes. 1
• However, this specific guidance applies to adults; pediatric guidelines still recommend PPSV23 for high-risk children after PCV13 to achieve the broader 23-serotype coverage. 1, 3
• As PCV20 becomes more widely used in pediatrics, guidelines may evolve to eliminate the need for PPSV23 in children receiving PCV20, but current pediatric recommendations are based on PCV13 data. 1

Timing for Planned Procedures

• When elective splenectomy, immunosuppressive therapy, or cochlear implant placement is planned, complete all pneumococcal vaccinations at least 2 weeks before the procedure. 2