Vaccination Guidelines for Adults

Introduction to Vaccination Recommendations

• The Centers for Disease Control and Prevention (CDC) recommends a single dose of PCV20 for all adults aged ≥65 years and adults 19-64 years with underlying medical conditions, or alternatively, PCV15 followed by PPSV23 at least 1 year later, as supported by the American College of Physicians and other organizations 1, 2, 3
• The primary recommendation is a single dose of PCV20, with an alternative option of a single dose of PCV15, followed by PPSV23 ≥1 year later, providing broader serotype coverage through higher-valency conjugate vaccines 1

Qualifying Conditions for Vaccination

• Qualifying conditions for vaccination include alcoholism, chronic heart disease, chronic liver disease, chronic lung disease, cigarette smoking, and diabetes mellitus, as well as congenital or acquired asplenia, sickle cell disease/other hemoglobinopathies, chronic renal failure, congenital or acquired immunodeficiencies, HIV infection, malignancies, iatrogenic immunosuppression, and solid organ transplant 1, 2

Updates to Vaccination Recommendations

• The 2019 update removed the routine PCV13 recommendation for immunocompetent adults ≥65 years, changing to a shared clinical decision-making approach, with a strength of evidence considered high by the CDC 2
• For adults who have received PPSV23, PCV20 should be administered after a ≥1 year interval since the PPSV23 dose, and for adults who have received PCV13, PCV20 should be administered after a ≥1 year interval since the PCV13 dose, as recommended by the CDC and supported by the ACIP 1
• The CDC recommends maintaining at least a 1-year interval between doses of PCV15 and PPSV23 for immunocompetent adults, to avoid diminished immune response, with a strength of evidence considered high by the CDC 2

Vaccination Schedule

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Special Populations

• Adults with immunocompromising conditions, such as HIV, malignancy, transplant recipients, should receive pneumococcal vaccination regardless of age, with a more aggressive schedule, as recommended by the Infectious Diseases Society of America (IDSA) and the CDC 2, 3, 1
• Patients who have undergone a solid organ transplant or hematopoietic stem cell transplantation (HSCT) require a specialized schedule of 3-4 doses of PCV20 (or PCV15), 4 weeks apart, starting 3-6 months after transplant, with a fourth dose administered at least 6 months after the third dose or at least 12 months after transplant, whichever is later, as recommended by the CDC and supported by the ACIP 1, 3

Efficacy and Effectiveness

• Sequential PCV13/PPSV23 vaccination has shown high effectiveness (80.3%) against pneumococcal community-acquired pneumonia in adults aged 65-74 years, compared to single-dose PCV13 (66.4%) or PPSV23 (18.5%), as reported by the CDC 2
• PCV13 has demonstrated efficacy against vaccine-type invasive pneumococcal disease (IPD) and pneumonia in adults aged ≥65 years with or without underlying chronic conditions, establishing an immune state that results in recall anti-pneumococcal responses upon subsequent vaccination with either conjugated or free polysaccharide vaccine, with a strength of evidence considered high by the CDC 3
• The newer PCV20 provides coverage for 7 additional serotypes beyond PCV13, offering broader protection, as stated in the context of the 2019 ACIP guidelines, with a strength of evidence considered high by the CDC 2

Economic Considerations

• Economic analyses have influenced recommendation changes, including cost-effectiveness ratios for universal PCV13 use in adults ≥65 years estimated at $200,000 to $560,000 per QALY in 2019, as reported by the CDC and supported by the ACIP, with a strength of evidence considered high by the CDC 2, 1
• The 2023 ACIP recommendations simplify the pneumococcal vaccination schedule while providing broader serotype coverage through the newer higher-valency conjugate vaccines (PCV15, PCV20), with a strength of evidence considered high by the CDC 1