Pneumococcal Vaccination Recommendations

Current ACIP Recommendations for Adults ≥65 Years

The American College of Physicians and the Advisory Committee on Immunization Practices (ACIP) recommend a single dose of PCV20 as the preferred option for adults aged ≥65 years who have never received a pneumococcal vaccine 1
For adults aged ≥65 years who have never received a pneumococcal vaccine, the ACIP recommends two options: a single dose of PCV20 or a single dose of PCV15 followed by a dose of PPSV23 at least 1 year later 1, 2
The 2023-2024 ACIP guidelines have updated the pneumococcal vaccination recommendations to include newer conjugate vaccines (PCV15, PCV20, and most recently PCV21) which provide broader serotype coverage 1

Vaccination Schedule Based on Prior Vaccination Status

If the patient has never received any pneumococcal vaccine, the ACIP recommends administering a single dose of PCV20 (preferred option for simplicity) 1
If the patient previously received PPSV23 before age 65, the ACIP recommends administering a single dose of PCV20 at least 1 year after the last PPSV23 dose 1
If the patient previously received PCV13, the ACIP recommends administering a single dose of PCV20 or PPSV23 at least 1 year after the PCV13 dose 1

Special Considerations

For immunocompromised adults or those with cerebrospinal fluid leaks or cochlear implants, the vaccination schedule is more aggressive with shorter intervals between doses 3, 4
PCV13 is no longer routinely recommended for all adults aged ≥65 years since 2019, as it has been replaced by newer pneumococcal conjugate vaccines with broader coverage 3, 5
The PPSV23 vaccine contains 11 additional serotypes not included in PCV13, which account for 32-37% of invasive pneumococcal disease among adults aged ≥65 years 5

Implementation Guidance

Pneumococcal vaccines should not be co-administered with each other 5
Avoid unnecessary revaccination with PPSV23 after the dose administered at age ≥65 years, as no additional doses are recommended 5, 6
PCV and PPSV23 should not be coadministered on the same day 5

Pneumococcal Vaccination Recommendations

Evolution of Recommendations

Prior to 2019, the recommendation was for all adults ≥65 years to receive both PCV13 and PPSV23, as reported by the Morbidity and Mortality Weekly Report 7
In 2019, routine PCV13 was no longer recommended for all adults ≥65 years, with PPSV23 remaining the primary recommendation, according to the Morbidity and Mortality Weekly Report 7

Pneumococcal Vaccination Recommendations for Adults

Recommendations for Adults with Prior Vaccination History

For adults aged ≥65 years who previously received PPSV23 at age ≥65 years, no additional doses of PPSV23 should be administered, as recommended by the Centers for Disease Control and Prevention (CDC) 8

Special Considerations for High-Risk Conditions

Adults with immunocompromising conditions, such as congenital or acquired asplenia, sickle cell disease, chronic renal failure, congenital or acquired immunodeficiencies, HIV infection, and malignancies with immunosuppressive treatments, require a more aggressive vaccination schedule with shorter intervals between doses, according to the CDC 8
The CDC recommends pneumococcal vaccination for adults with high-risk conditions, including congenital or acquired asplenia 9, sickle cell disease/other hemoglobinopathies 8, chronic renal failure 9, congenital or acquired immunodeficiencies 8, HIV infection 9, and malignancies and immunosuppressive treatments [9] [8]

Pneumococcal Vaccination Update Frequency

Standard Recommendations by Age and Risk Status

The Centers for Disease Control and Prevention recommends that adults 19-64 years with chronic medical conditions follow the same one-time series approach: PCV20 alone or PCV15 followed by PPSV23 after ≥1 year, and review vaccination status again when turning 65 years old to determine if additional doses are needed based on prior vaccination history 10
The Centers for Disease Control and Prevention suggests that adults with immunocompromising conditions may require multiple doses, with an initial series of PCV20 alone or PCV15 followed by PPSV23 after ≥8 weeks, and PPSV23 boosters given ≥5 years after the first PPSV23 10

Special Considerations for Immunocompromised Patients

The Centers for Disease Control and Prevention recommends that immunocompromising conditions include chronic renal failure, asplenia, HIV infection, malignancies, immunosuppressive therapy, sickle cell disease, transplant recipients, and complement deficiencies, and that these patients require shorter intervals (≥8 weeks vs ≥1 year) between PCV and PPSV23 10

Patients with Prior Vaccination History

The Centers for Disease Control and Prevention suggests that patients who previously received PPSV23 only should be given PCV20 or PCV15 after waiting ≥1 year from the last PPSV23 dose 10
The Centers for Disease Control and Prevention recommends that patients who previously received PCV13 only and are immunocompromised should add PPSV23 ≥8 weeks after PCV13, then a second PPSV23 ≥5 years later 10
The Centers for Disease Control and Prevention suggests that patients who previously received both PCV13 and PPSV23 and are <65 years with immunocompromising conditions may give PCV20 ≥5 years after last dose 10

Pneumococcal Vaccination Recommendations

Adult Vaccination Guidelines

The Centers for Disease Control and Prevention recommends that adults who receive PPSV23 at age ≥65 years should receive only a single dose, without additional boosters 11
Adults who received PPSV23 before age 65 for any indication should receive another dose of the vaccine at age ≥65 years, if at least 5 years have passed since the previous dose 11
A second dose of PPSV23 is recommended 5 years after the first dose for persons aged 19-64 years with specific high-risk conditions, such as asplenia or immunocompromising conditions 11
The Advisory Committee on Immunization Practices does not recommend multiple revaccinations due to uncertainty regarding clinical benefit and safety 11

Vaccine Selection and Administration

The latest recommendations (2024) emphasize the use of newer conjugate vaccines (PCV20, PCV21, PCV15) as preferred options 12
For adults ≥65 years who have received only PPSV23 in the past, a single dose of PCV20 or PCV15 is recommended ≥1 year after the last dose of PPSV23 12
If an adult has completed the series with PCV13 and PPSV23 at age ≥65 years, shared clinical decision-making may be considered to administer PCV20 or PCV21 ≥5 years after the last dose of pneumococcal vaccine 12

Pneumococcal Vaccination Guidelines

Introduction to PPSV23 Vaccination

Most adults receive only one or two lifetime doses of PPSV23, depending on age and risk factors, with specific 5-year intervals applying only to select high-risk populations who received their first dose before age 65, as recommended by the Centers for Disease Control and Prevention 13, 14

Standard PPSV23 Dosing for High-Risk Adults

A second dose of PPSV23 is recommended 5 years after the first dose for persons aged 19-64 years with specific high-risk conditions, such as immunocompromising conditions, according to the Advisory Committee on Immunization Practices 13, 14
For immunocompromised adults aged 19-64 years who received both PCV13 and one dose of PPSV23, a second PPSV23 dose may be given ≥5 years after the first PPSV23 dose, as stated by the Centers for Disease Control and Prevention 13

Current Preferred Approach: Conjugate Vaccines First

The 2024 Advisory Committee on Immunization Practices guidelines recommend newer conjugate vaccines (PCV20, PCV21, or PCV15) as the preferred initial vaccination for adults ≥65 years, not PPSV23, with a strength of evidence rated as high 13
For adults who previously received only PPSV23, a single dose of PCV20, PCV21, or PCV15 should be administered ≥1 year after the last PPSV23 dose, completing the series, as recommended by the Centers for Disease Control and Prevention 13, 14

Pneumococcal Vaccination Timing

Timing Based on Immune Status

The CDC Advisory Committee on Immunization Practices (ACIP) recommends that PPSV23 should be given at least 8 weeks after PCV13 for adults with immunocompromising conditions, including chronic renal failure, asplenia, HIV infection, malignancies, immunosuppressive therapy, sickle cell disease, transplant recipients, and complement deficiencies 15, 16
For children aged 2-18 years with underlying medical conditions, PPSV23 should be administered at least 8 weeks after the most recent dose of PCV13, as recommended by the CDC 17
The American College of Physicians and other guideline societies support the recommendation that for immunocompetent adults aged 65 years or older, PPSV23 should be given at least 1 year after PCV13 18, 19
Among those previously immunized with PPSV23, immunocompromised adults should receive PCV13 at least one year after receipt of the most recent PPSV23 dose, according to the Autoimmunity Reviews 15, 16

Clinical Rationale for Different Intervals

The shorter 8-week interval for immunocompromised patients reflects the greater urgency for protection in patients at higher risk for invasive pneumococcal disease, as stated in Clinical Infectious Diseases 20
Adequate immune priming occurs within 8 weeks even in immunosuppressed states, as demonstrated in Annals of the Rheumatic Diseases 21

Important Caveats

For patients requiring elective splenectomy or initiation of immunosuppressive therapy, vaccination should be completed at least 2 weeks before surgery or therapy initiation, as recommended by the MMWR Recommendations and Reports 17
A second dose of PPSV23 is recommended 5 years after the first dose for immunocompromised patients, according to the MMWR Recommendations and Reports 17

PPSV23 Vaccination Dose Series for High-Risk Adults

Vaccination Recommendations

The Centers for Disease Control and Prevention recommends that adults who previously received only PPSV23 should receive a single dose of PCV20, PCV21, or PCV15 at least 1 year after the last PPSV23 dose, completing the series without additional PPSV23, for adults aged 50 years and older 22
For immunocompromised adults requiring both PCV and PPSV23, the minimum interval between vaccines is at least 8 weeks, applicable to adults with chronic renal failure, asplenia, HIV infection, malignancies, immunosuppressive therapy, sickle cell disease, transplant recipients, and complement deficiencies 22

Conjugate Vaccine Preferences

The Advisory Committee on Immunization Practices recommends newer conjugate vaccines, such as PCV20, PCV21, or PCV15, as the preferred initial vaccination for adults aged 50 years and older, rather than PPSV23, with PCV15 to be followed by PPSV23 at least 1 year later for immunocompetent adults 22

Pneumococcal Vaccination Guidelines for Elderly Patients

Vaccination Recommendations

The Centers for Disease Control and Prevention recommends that if vaccination status is uncertain, do not delay vaccination - use the patient's verbal history and proceed with vaccination if indicated 23, 24
For immunocompromised patients, such as those with chronic renal failure or nephrotic syndrome, functional or anatomic asplenia, HIV infection, malignancies, or immunosuppressive therapy, a shorter interval of 8 weeks is recommended between vaccines 23, 24
The Advisory Committee on Immunization Practices suggests that for adults who received PPSV23 before age 65, a second dose of PPSV23 is recommended 5 years after the first dose 23, 24
It is recommended to document vaccination clearly to avoid unnecessary future doses, but never withhold vaccination due to missing records 23, 24
The Centers for Disease Control and Prevention advises against delaying vaccination waiting for complete medical records - use verbal history and proceed 23, 24
It is also recommended to avoid giving multiple PPSV23 boosters beyond what is recommended, as there is insufficient evidence for safety with three or more doses 23, 24

Pneumococcal Vaccination Guidelines

Standard Duration of Protection

For adults aged ≥65 years, the Centers for Disease Control and Prevention (CDC) recommends that the current pneumococcal vaccines (PCV20, PCV21, or PCV15/PPSV23 series) are considered lifetime vaccinations with no routine booster doses recommended after completion of the series 25
If the PCV15/PPSV23 series is used, the PPSV23 dose given at age ≥65 years is the final pneumococcal vaccine—no additional boosters are recommended 26

Special Populations Requiring Different Schedules

For adults with immunocompromising conditions, the initial series is PCV20 alone or PCV15 followed by PPSV23 at ≥8 weeks, and a second dose of PPSV23 is recommended 5 years after the first PPSV23 dose for those who received their first dose before age 65 25, 26

Critical Timing Intervals Between Doses

The CDC recommends specific intervals between pneumococcal vaccine doses, including ≥1 year between PCV and PPSV23 for immunocompetent adults, and ≥8 weeks between PCV and PPSV23 for immunocompromised adults 25

Pneumococcal Vaccination Guidelines

Introduction to Pneumococcal Vaccines

The Centers for Disease Control and Prevention recommends pneumococcal vaccination for adults aged ≥65 years without prior pneumococcal vaccination, with a single dose of PCV20 (20-valent pneumococcal conjugate vaccine) as the preferred option, which completes the series with no additional doses needed 27
Three pneumococcal vaccines are currently used in adults: PCV20, PCV15, and PPSV23, according to the MMWR Recommendations and Reports 27, 28

Vaccination Schedule for Adults

For adults with no prior pneumococcal vaccination, the American College of Physicians recommends administering PCV20 or PCV15 followed by PPSV23 at least 1 year later, with PCV20 being the preferred option 27, 28
For adults who previously received PPSV23 only, the Centers for Disease Control and Prevention recommends administering PCV20 or PCV15 at least 1 year after the last PPSV23 dose 27, 28
For adults with chronic medical conditions, such as chronic heart disease, chronic lung disease, or diabetes mellitus, the MMWR Recommendations and Reports suggest administering PCV20 as a single dose or PCV15 followed by PPSV23 at least 1 year later 28, 29
For adults with immunocompromising conditions, such as HIV infection or immunosuppressive therapy, the Centers for Disease Control and Prevention recommends administering PCV20 or PCV15 followed by PPSV23 at least 8 weeks later 27, 28, 29

Critical Timing Rules

The MMWR Recommendations and Reports advise against coadministering pneumococcal vaccines on the same day, as this reduces immune response and wastes the vaccine 27
The interval between PCV and PPSV23 should be at least 1 year for immunocompetent adults and at least 8 weeks for immunocompromised adults 27
If PPSV23 was given first, the Centers for Disease Control and Prevention recommends waiting at least 1 year before giving PCV20 or PCV15 27, 28

Maximum Lifetime PPSV23 Doses

The Morbidity and Mortality Weekly Report states that immunocompetent adults should receive a maximum of 1-2 doses total, while immunocompromised adults should receive a maximum of 2-3 doses total 29
No additional PPSV23 doses should be given after the dose administered at age ≥65 years 29

Pneumococcal Vaccination Completion After Single PPSV23 Dose

Clinical Rationale

The Centers for Disease Control and Prevention (CDC) emphasizes that all adults ≥65 years should continue to receive PPSV23, according to the 2019 ACIP guidelines 30

Evidence Quality and Guideline Evolution

The American College of Physicians (ACP) and the CDC recommend adding conjugate vaccines for patients who previously received only PPSV23, representing a significant evolution from the 2019 ACIP guidelines, with moderate to high strength of evidence 30

Pneumococcal Vaccination Guidelines for Adults

Recommended Vaccination Schedule

The Centers for Disease Control and Prevention (CDC) recommends administering a single dose of PCV20 at least 1 year after the last PPSV23 dose for adults ≥65 years or with high-risk conditions who have already received one dose of PPSV23, completing the pneumococcal vaccination series with no additional doses needed 31
The American College of Physicians (ACP) and CDC agree that the same ≥1 year interval applies to both immunocompetent adults ≥65 years and those with chronic medical conditions when transitioning from PPSV23 to PCV20 31
For immunocompromised patients, the CDC recommends the same ≥1 year interval when transitioning from PPSV23 to PCV20, with no additional doses needed after PCV20 administration 31

Clinical Rationale

The 2023 ACIP guidelines updated recommendations to include conjugate vaccine administration for patients who previously received only PPSV23, providing enhanced immunologic response and broader serotype coverage 31
The CDC presented this as formal implementation guidance, representing the highest quality guideline evidence available, with a strong recommendation for PCV20 administration at least 1 year after the last PPSV23 dose 31

Special Population Considerations

For patients who received PPSV23 before age 65 and are now ≥65 years, the CDC recommends administering PCV20 at least 1 year after the last PPSV23 dose, completing the series regardless of when the PPSV23 was given 31
The CDC also recommends that immunocompromised patients follow the same ≥1 year interval when transitioning from PPSV23 to PCV20, with no additional doses needed after PCV20 administration 31

Alternative Option

If PCV20 is not available, the CDC recommends administering PCV15 at least 1 year after the last PPSV23 dose as an alternative, completing the series with no additional PPSV23 needed 31

ACIP Recommendations on Pneumococcal Vaccination for Adults ≥ 65 Years

Standard Recommendations

Adults ≥ 65 years should receive only one dose of PPSV23; no additional PPSV23 doses are recommended after the dose given at age ≥ 65. (Advisory Committee on Immunization Practices, 2023) 32
If an individual has already completed the recommended pneumococcal series—either PCV13 followed by PPSV23 at age ≥ 65, or a single dose of PCV20—no further pneumococcal vaccinations are advised because no additional clinical benefit has been demonstrated. (Advisory Committee on Immunization Practices, 2023) 33

Optional Exception (Shared Decision‑Making)

For adults who received PCV13 + PPSV23 at least five years earlier, shared clinical decision‑making may be used to consider a single dose of PCV20; this is an optional, not routine, recommendation. (Advisory Committee on Immunization Practices, 2023) 32

ACIP Recommendations for PCV13 and PPSV23 Sequencing (2014‑2021)

Historical Sequence Recommendations

The Advisory Committee on Immunization Practices (ACIP) recommended that all adults ≥ 65 years receive both PCV13 and PPSV23 in sequence, with PCV13 administered first. 34
For immunocompetent adults ≥ 65 years, the interval was PCV13 first, then PPSV23 at least 1 year later. [34][35]
For immunocompromised adults (any age ≥ 19 years), the interval was PCV13 first, then PPSV23 at least 8 weeks later. 34
If PPSV23 was given before PCV13, a minimum interval of 1 year was required before administering PCV13. [34][35]

2019 Policy Update

In 2019, ACIP changed PCV13 from a routine recommendation to shared clinical decision‑making for immunocompetent adults ≥ 65 years, while maintaining PPSV23 as a universal recommendation. 35
This change was driven by the substantial indirect protection conferred by pediatric PCV13 vaccination, which markedly reduced PCV13‑type disease in older adults. 35
PCV13 remained a routine recommendation (not shared decision‑making) for adults with immunocompromising conditions, cerebrospinal‑fluid leaks, or cochlear implants. 35

Timing for Peri‑operative and Immunosuppressive Therapy

For patients scheduled for elective splenectomy or initiation of immunosuppressive therapy, the pneumococcal vaccination series should be completed at least 2 weeks before surgery or therapy start. 34

PPSV23 Revaccination Rules

Adults who receive PPSV23 at age ≥ 65 years should receive only one dose; no additional PPSV23 doses are recommended after that dose. 34
Adults who received PPSV23 before age 65 for any indication should receive a second dose at age ≥ 65 years if ≥ 5 years have elapsed since the prior dose. 34
For persons aged 19‑64 years with immunocompromising conditions (e.g., chronic renal failure, asplenia, HIV infection, malignancies, immunosuppressive therapy), a second PPSV23 dose is recommended 5 years after the first dose. 34

ACIP Recommendations for Adult Pneumococcal Vaccination (2019)

Change in PCV13 Recommendation for Immunocompetent Adults ≥ 65 years

The Advisory Committee on Immunization Practices (ACIP) revised its 2019 guidance, shifting PCV13 from a universal recommendation to a shared clinical‑decision‑making approach for immunocompetent adults aged ≥ 65 years, reflecting the substantial indirect protection achieved through routine pediatric PCV13 use. 36, 37

Residual Disease Burden After Pediatric PCV13 Introduction

Following widespread pediatric PCV13 immunization, the incidence of invasive pneumococcal disease caused by PCV13 serotypes in adults fell to approximately 5 cases per 100,000 population, accounting for about 20 % of all invasive pneumococcal disease—a historically low level. 36

Routine PCV13 Recommendation for High‑Risk Adult Groups

ACIP continues to recommend routine (non‑shared‑decision) PCV13 vaccination for adults with immunocompromising conditions, cerebrospinal‑fluid leaks, or cochlear implants. 36, 37

Recommended Interval After PCV13 for Subsequent PPSV23 Dose

Immunocompetent Adults

For adults without immunocompromising conditions, ACIP advises an interval of ≥ 1 year between administration of PCV13 and a subsequent PPSV23 dose. 36, 37

Immunocompromised Adults

For adults with immunocompromising conditions, ACIP recommends a shorter interval of ≥ 8 weeks between PCV13 and PPSV23 to provide more rapid protection. 36, 37