Can a 60‑year‑old current smoker with unknown pneumococcal vaccination history receive a respiratory syncytial virus vaccine (Arexvy or Pfizer RSV vaccine) and recombinant zoster vaccine (Shingrix) at the same visit as the 20‑valent pneumococcal conjugate vaccine (PCV20)?

Co-Administration of RSV, Shingrix, and PCV20 Vaccines

Yes, a 60-year-old current smoker can receive RSV vaccine, Shingrix, and PCV20 at the same visit—all three vaccines may be co-administered simultaneously at different injection sites. 1

Evidence Supporting Co-Administration

RSV Vaccine Co-Administration Guidance

• The Advisory Committee on Immunization Practices explicitly states that administration of RSV vaccine with other adult vaccines during the same visit is acceptable. 1
• RSV vaccines can be co-administered with seasonal influenza vaccine at separate injection sites, and this principle extends to other adult vaccines. 1
• While specific data on simultaneous administration with pneumococcal and herpes zoster vaccines are currently lacking, ACIP does not prohibit this practice. 1

Shingrix and PCV Co-Administration Evidence

• A randomized controlled trial demonstrated that Shingrix (recombinant zoster vaccine) co-administered with PCV13 had an acceptable safety profile, with non-inferior immune responses compared to sequential administration. 2
• The frequency of local adverse events upon co-administration was consistent with the known safety profile of each individual vaccine. 2
• Humoral immune responses to both vaccines were non-inferior when co-administered compared to sequential administration. 2
• These results suggest that adults may benefit from receiving Shingrix and a pneumococcal conjugate vaccine at the same healthcare visit. 2

Pneumococcal Vaccine Eligibility for This Patient

• This 60-year-old current smoker qualifies for PCV20 based on cigarette smoking, which is classified as a chronic medical condition indication. 1
• For adults aged 19-64 years with chronic medical conditions (including cigarette smoking), ACIP recommends administering a single dose of PCV20 if no prior pneumococcal vaccination has been documented. 1
• The Advisory Committee on Immunization Practices expanded age-based PCV recommendations in October 2024 to include all adults aged ≥50 years, making this patient eligible regardless of smoking status. 3

RSV Vaccine Eligibility for This Patient

• Adults aged 60-74 years with chronic respiratory conditions or cigarette smoking should receive RSV vaccination. 1, 4
• Cigarette smoking is recognized as a risk factor for severe RSV disease in this age group. 4
• Patient attestation alone is sufficient evidence of risk factors; vaccination should not be denied due to lack of medical documentation. 4

Practical Implementation

Injection Site Strategy

• Administer each vaccine at a separate anatomic site (e.g., one in each deltoid, one in the thigh if needed). 1, 2
• Document the specific anatomic location of each vaccine administered. 2

Timing Considerations

• If possible, schedule this visit in late summer or early fall (August-October) to optimize RSV vaccine protection before RSV season begins. 1, 4
• PCV20 and Shingrix can be administered at any time of year without seasonal considerations. 1, 3

Expected Adverse Events

• Patients should be counseled that receiving multiple vaccines simultaneously may result in additive local reactions at each injection site. 2
• Solicited general adverse events (fatigue, myalgia, headache) when co-administering vaccines are within the same range as for individual vaccines. 2
• The safety profile of co-administration is acceptable and does not contraindicate simultaneous administration. 2

Important Clinical Caveats

Guillain-Barré Syndrome Risk with RSV Vaccines

• Patients receiving protein-subunit RSV vaccines (Arexvy or Abrysvo) should be informed of the potential increased risk of Guillain-Barré syndrome. 4
• This is a precaution, not a contraindication, and the benefits of vaccination in this high-risk patient substantially outweigh potential harms. 4

Single Lifetime Doses

• RSV vaccine is a single lifetime dose—this patient should not receive another RSV vaccine dose in the future. 1, 4
• PCV20 is also a single dose for this indication; no additional pneumococcal vaccination is needed unless the patient develops immunocompromising conditions. 1
• Shingrix requires a two-dose series; the second dose should be administered 2-6 months after the first dose. 2

Documentation Requirements

• Patient self-attestation of smoking status is sufficient to establish eligibility for both RSV and pneumococcal vaccines; formal medical records are not required. 4
• Providers should not delay vaccination while waiting for documentation of risk factors. 4