What are the recommendations and guidelines for administering the Pneumococcal Conjugate Vaccine (PCV) to children and high-risk adults, including those with compromised immune systems or a history of severe allergic reactions?

Pneumococcal Conjugate Vaccine (PCV) Recommendations

Children: Universal Vaccination Schedule

All children should receive PCV13 starting at 2 months of age with doses at 2,4,6, and 12-15 months. 1

• The minimum age for initiating PCV vaccination is 6 weeks, with the standard schedule being 2,4,6, and 12-15 months of age 1, 2
• For children who start vaccination late (7-23 months), a reduced number of doses is appropriate based on age at initiation 2
• The vaccine should be administered concurrently with other routine childhood vaccines at the same visit 2

High-Risk Children (Ages 6-18 Years)

Children aged 6-18 years with immunocompromising conditions, functional or anatomic asplenia, CSF leaks, or cochlear implants should receive PCV13 regardless of prior PCV7 or PPSV23 vaccination. 1

Specific High-Risk Conditions Include:

• HIV infection (IPD incidence rate ratio of 122 compared to healthy children) 1
• Hematologic malignancies (IPD incidence rate ratio of 822) 1
• Sickle cell disease (IPD incidence rate ratio of 27) 1
• Functional or anatomic asplenia 1
• Chronic renal failure, nephrotic syndrome, or dialysis 3
• CSF leaks or cochlear implants 1

Vaccination Sequence for High-Risk Children:

• Administer PCV13 first, followed by PPSV23 at least 8 weeks later to expand serotype coverage 1
• This represents a change from the previous permissive recommendation to a Category A (routine) recommendation 1

Adults ≥65 Years: Standard Recommendations

All adults aged ≥65 years should receive PPSV23 as the standard recommendation, with PCV13 no longer routinely recommended since 2019. 1, 4

Current Adult Vaccination Approach:

• For vaccine-naïve adults ≥65 years: Administer a single dose of PCV20 as the preferred option, or alternatively PCV15 followed by PPSV23 at least 1 year later. 3
• If PCV20 is unavailable, give PCV15 followed by PPSV23 after a minimum interval of ≥1 year 3
• The 2019 policy change eliminated routine PCV13 use due to sustained indirect protection from pediatric vaccination programs reducing PCV13-type disease burden 1

Shared Clinical Decision-Making for PCV13:

PCV13 may be considered through individualized assessment for adults in high-exposure scenarios, including: 1, 4

• Nursing home or long-term care facility residents 1
• Persons in settings with low pediatric PCV13 uptake 1
• Travelers to settings without pediatric PCV13 programs 1

If PCV13 is administered, it must be given at least 1 year before PPSV23. 1, 4

Adults ≥19 Years with High-Risk Conditions

Adults aged ≥19 years with immunocompromising conditions, CSF leaks, or cochlear implants should receive PCV13 (or PCV20/PCV15) in series with PPSV23. 1

Vaccination Schedule for Immunocompromised Adults:

• Administer PCV13, PCV20, or PCV15 first, NOT PPSV23 5
• If PCV15 is selected, follow with PPSV23 at least 8 weeks later (not 1 year) due to immunocompromised status 3, 5
• A second dose of PPSV23 is recommended ≥5 years after the first PPSV23 dose 4, 3

Special Populations:

Diabetic patients aged ≥65 years: Administer a single dose of PCV20 as preferred, or PCV15 followed by PPSV23 at least 1 year later, as diabetes significantly increases pneumococcal infection risk with mortality rates up to 50% for bacteremic disease 3

Cancer patients on immunosuppressive therapy: Complete pneumococcal vaccination at least 2 weeks before initiating treatment when possible; if already on therapy, proceed with PCV20, PCV21, or PCV15 now rather than delaying, as inactivated vaccines pose no safety concerns during cancer treatment 5

Critical Timing and Administration Rules

Intervals Between Vaccines:

• Never co-administer PCV13 and PPSV23 on the same day 4, 3
• Immunocompetent adults: PCV13 or PCV15 should precede PPSV23 by at least 1 year 4, 3
• Immunocompromised adults: Shortened interval of ≥8 weeks between PCV15 and PPSV23 3, 5

Prior Vaccination History:

• If previously received PPSV23 only: Administer PCV20 or PCV15 at least 1 year after the last PPSV23 dose 3
• If previously received PCV13 only: Administer PCV20 at least 1 year after PCV13, or PPSV23 if PCV20 unavailable 3

Optimal Timing for High-Risk Patients:

• Complete vaccination at least 2 weeks before elective splenectomy or initiation of immunosuppressive therapy 3, 5

Contraindications and Safety

Severe allergic reaction (anaphylaxis) to a previous dose of PCV or any vaccine component is the only absolute contraindication. 1

Safety Profile:

• Both PCV13 and PPSV23 have similar safety profiles with comparable rates of severe adverse events 4
• Common PCV13 reactions include injection site pain (20% tenderness), redness, swelling, arm movement limitation, fatigue, headache, chills, decreased appetite, muscle pain, and joint pain 4
• Fever ≥38°C occurs in 15-25% of children in the first two days following vaccination 6

Co-administration:

• Pneumococcal vaccines can be safely co-administered with influenza, COVID-19, and other age-appropriate vaccines at different anatomic sites during the same visit 4, 5

Key Clinical Pitfalls to Avoid

• Do not give PPSV23 first in immunocompromised patients – always start with PCV13, PCV15, or PCV20 for optimal immune priming 5
• Do not use the 1-year interval for immunocompromised patients – they require the shorter 8-week interval between PCV15 and PPSV23 3, 5
• Do not unnecessarily revaccinate with PPSV23 after the dose given at age ≥65 years unless specific high-risk conditions warrant it 3
• Do not delay vaccination in cancer patients – proceed now rather than waiting, as inactivated vaccines are safe during immunosuppressive therapy 5