What are the pneumococcal vaccination guidelines for children under 2 years, adults 19‑64 with chronic or immunocompromising conditions, and adults 65 years or older?

Pneumococcal Vaccination Recommendations

Children Under 2 Years

All children under 2 years should receive a routine pneumococcal conjugate vaccine series starting at 6 weeks of age, with options including PCV20, PCV15, or PCV13 depending on availability. 1, 2

• The standard infant series consists of doses administered at 2,4,6, and 12-15 months of age 1
• PCV20 and PCV15 are licensed for use starting at 6 weeks of age 1
• Children in this age group do not develop an effective immune response to polysaccharide vaccines (PPSV23), which is why conjugate vaccines are essential 3

Adults Aged 19-64 Years with Chronic or Immunocompromising Conditions

Adults aged 19-64 years with chronic medical conditions or immunocompromising conditions should receive a single dose of PCV20 (preferred) or PCV15 followed by PPSV23. 1, 4

Chronic Medical Conditions (Immunocompetent)

• Chronic conditions include chronic heart disease, chronic lung disease, chronic liver disease, diabetes mellitus, alcoholism, and cigarette smoking 4, 5
• Current smokers have 2.8-4.1 times the risk for invasive pneumococcal disease compared with adults without underlying risk conditions 4
• Administer a single dose of PCV20, which completes the pneumococcal vaccination series with no additional doses needed 4, 5
• Alternative: PCV15 followed by PPSV23 at least 1 year later 1, 2

Immunocompromising Conditions

• Immunocompromising conditions include HIV infection, congenital or acquired immunodeficiencies, iatrogenic immunosuppression, generalized malignancy, Hodgkin disease, leukemia, lymphoma, multiple myeloma, chronic renal failure, nephrotic syndrome, asplenia, sickle cell disease, and solid organ transplant recipients 1, 4, 6
• Administer a single dose of PCV20 (preferred), which completes the series 4, 5
• Alternative: PCV15 followed by PPSV23 at least 8 weeks later (not 1 year—this is the critical distinction for immunocompromised patients) 6, 5
• If the alternative regimen is used, a second dose of PPSV23 is recommended 5 years after the first PPSV23 dose for those who received their first dose before age 65 1, 6

Special Populations: CSF Leak or Cochlear Implant

• Adults with cerebrospinal fluid leaks or cochlear implants follow the same accelerated schedule as immunocompromised patients 1, 5
• PCV first, then PPSV23 at least 8 weeks later 5

Adults Aged 50-64 Years (Expanded 2024 Recommendation)

As of October 2024, all adults aged ≥50 years should receive a single dose of PCV (PCV20 or PCV21) regardless of underlying conditions. 7

• This represents an expansion from the previous age-based recommendation that began at 65 years 7
• A single dose of PCV20 or PCV21 completes the series for healthy adults in this age group 7

Adults Aged 65 Years or Older

All adults aged ≥65 years should receive pneumococcal conjugate vaccine, with a single dose of PCV20 or PCV21 as the preferred option. 1, 4

Vaccine-Naïve Adults ≥65 Years

• Administer a single dose of PCV20 or PCV21 (preferred), which completes the series with no additional doses needed 4, 6, 5
• Alternative: PCV15 followed by PPSV23 at least 1 year later 1, 2
• No booster doses are recommended after completing this series 5

Adults ≥65 Years with Prior PPSV23 Only

• Administer a single dose of PCV20 or PCV21 at least 1 year after the last PPSV23 dose, which completes the series 4, 6, 5
• No additional pneumococcal vaccines are needed after PCV20/PCV21 administration 4, 6

Adults ≥65 Years with Prior PCV13 Only

• Administer a single dose of PCV20 or PCV21 at least 1 year after the PCV13 dose, which completes the series 4, 6, 5
• No additional vaccines are needed after PCV20/PCV21 4

Adults ≥65 Years Who Completed PCV13 + PPSV23 Series

• If both PCV13 and PPSV23 were received with the PPSV23 dose given at age ≥65 years, the pneumococcal vaccination series is complete 6
• Shared clinical decision-making may be used to consider a single dose of PCV20 or PCV21 ≥5 years after the last pneumococcal vaccine dose; this is optional, not routine 1, 4, 6
• This represents an optional additional dose for potential expanded serotype coverage, particularly for immunocompromised patients 4

Critical Timing Intervals to Avoid Errors

• Never coadminister pneumococcal vaccines on the same day—this reduces immune response and wastes the vaccine 5
• Immunocompetent adults: ≥1 year between PCV and PPSV23 6, 5
• Immunocompromised adults: ≥8 weeks between PCV and PPSV23 6, 5
• If PPSV23 was given first: wait ≥1 year before giving PCV20/PCV21 4, 6, 5
• For adults who received both PCV13 and PPSV23: wait ≥5 years before considering PCV20/PCV21 1, 4, 6

Maximum Lifetime PPSV23 Doses

• Immunocompetent adults: maximum of 1-2 doses total (one before age 65 if indicated, one at/after age 65) 5
• Immunocompromised adults: maximum of 2-3 doses total (initial dose, booster at 5 years if given before age 65, final dose at/after age 65) 5
• No additional PPSV23 doses are given after the dose administered at age ≥65 years 6, 5

Common Pitfalls

• Do not give PCV20/PCV21 too soon after prior pneumococcal vaccination—minimum intervals must be observed 4, 5
• Do not add PPSV23 after PCV20/PCV21—once PCV20 or PCV21 is administered, the series is complete 4, 6
• Do not confuse the 8-week interval (immunocompromised) with the 1-year interval (immunocompetent) 6, 5
• Do not give multiple PPSV23 boosters beyond what is recommended—there is insufficient evidence for safety with three or more doses 6
• If vaccination history is uncertain, do not delay vaccination—use verbal history and proceed with vaccination if indicated 6