Ask the Experts: Pneumococcal

Results (88)

Pneumococcal disease is caused by Streptococcus pneumoniae, a bacterium that has more than 100 serotypes. Most serotypes cause disease, but only a few produce the majority of invasive pneumococcal disease.

Last reviewed: July 26, 2022

The disease is spread from person to person by droplets in the air. The pneumococci bacteria are common inhabitants of the human respiratory tract. They may be isolated from the nasopharynx of 5%–90% of healthy people.

Last reviewed: July 26, 2022

There are two major clinical syndromes of invasive pneumococcal disease: bacteremia (blood stream infection), and meningitis (infection of the meninges that surround the brain). They are both caused by infection with the same bacteria, but produce different signs and symptoms.

Pneumococcal pneumonia is the most common disease caused by pneumococcal infection. An estimated 400,000 hospitalizations from pneumococcal pneumonia occur in the United States annually.

Pneumococcal pneumonia can occur in combination with bacteremia and/or meningitis (invasive pneumococcal pneumonia), or it can occur alone (non-invasive pneumococcal pneumonia). Non-invasive pneumococcal pneumonia can be severe. Symptoms include abrupt onset of fever, shaking chills or rigors, chest pain, cough, shortness of breath, rapid breathing and heart rate, and weakness. The fatality rate is 5%–7% and may be much higher in older adults. Pneumococcal bacteremia occurs in about 25%–30% of patients with pneumococcal pneumonia.

About 4,000 cases of pneumococcal bacteremia without pneumonia occur each year in the United States. Bacteremia is the most common clinical presentation among children less than two years, accounting for up to 70% of invasive disease in this age group.

Pneumococci cause 50% of all cases of bacterial meningitis in the United States. There are an estimated 2,000 cases of pneumococcal meningitis each year. Symptoms and signs may include headache, tiredness, vomiting, irritability, fever, seizures, and coma. The case-fatality rate of pneumococcal meningitis is about 8% among children and 22% among adults. Permanent neurological damage is common among survivors.

Last reviewed: July 26, 2022

Pneumococcal disease is a serious disease that causes much sickness and death. CDC estimates that more than 150,000 hospitalizations from pneumococcal disease occur annually in the U.S. An estimated 30,300 cases and 3,250 deaths from invasive pneumococcal diseases (IPD-bacteremia and -meningitis) occurred in the United States in 2019 (see www.cdc.gov/abcs/downloads/SPN_Surveillance_Report_2019.pdf.). Children younger than age two years and adults age 50 years and older) have the highest incidence of serious disease. Case-fatality rates are highest for pneumococcal meningitis and bacteremia, and the highest mortality occurs among older adults and patients who have underlying medical conditions. The overall case-fatality rate for pneumococcal bacteremia is about 20%. Among older adults, this rate may be as high as 60%.

Last reviewed: July 26, 2022

One pneumococcal polysaccharide vaccine (PPSV23, Pneumovax 23, Merck) and three pneumococcal conjugate vaccines [PCV13 (Prevnar 13, Pfizer), PCV15 (Vaxneuvance, Merck), and PCV20 (Prevnar 20, Pfizer)] are FDA-licensed and recommended by CDC for use in the United States.

PPSV23 is licensed for age 2 years and older. It was first licensed in 1983. It is recommended for children ages 2 years or older with specified risk factors for pneumococcal disease. It is recommended as an option, when used in series with PCV15, for adults 19 through 64 at increased risk for invasive pneumococcal disease due to behavioral or medical risk factors. A PCV15 + PPSV23 series also is recommended as an option for pneumococcal disease prevention in adults 65 years and older. Following the 2022 changes to the pneumococcal vaccination schedule for adults, PPSV23 is no longer recommended alone, however PPSV23 is recommended for adults after PCV13 or PCV15 vaccination. It is not recommended for people who have previously received a PCV20 vaccination.

PCV13 is licensed for people age 6 weeks and older and was first licensed in 2010. Following the 2022 changes to adult pneumococcal vaccination recommendations, it is only recommended for use in children through age 18 years. CDC recommends the use of PCV13 for the routine vaccination of children younger than 5 years of age (4-dose series at age 2 months, 4 months, 6 months, and 12–15 months) and children 6 years and older without prior PCV13 vaccination who have certain medical conditions that put them at high risk of invasive pneumococcal disease. It is no longer recommended for use in adults.

PCV15 was licensed in 2021 for people age 18 years and older. CDC recommends it as an option for pneumococcal disease prevention in adults age 19 years or older who have not previously received a pneumococcal conjugate vaccine. It is always recommended to be used as part of a vaccination series with PPSV23 typically given 1 year later (a minimum interval of 8 weeks may be considered for certain high-risk individuals). PCV15 followed by PPSV23 is an option for adults 19 through 64 at increased risk for invasive pneumococcal disease due to behavioral or medical risk factors or for adults age 65 or older.

PCV20 was licensed in 2021 for people age 18 years and older. CDC recommends it as an option for pneumococcal disease prevention in adults age 19 years or older who have not previously received a pneumococcal conjugate vaccine. If PCV20 is given, no further pneumococcal vaccination is recommended. PCV20 is an option for adults 19 through 64 at increased risk for invasive pneumococcal disease due to behavioral or medical risk factors or for adults age 65 or older.

Last reviewed: July 26, 2022

A polysaccharide vaccine is a type of vaccine that is composed of long chains of sugar molecules, called polysaccharides, that resemble the surface of certain serotypes of pneumococcal bacteria in order to help the immune system mount a response.

A conjugate vaccine is a type of vaccine that joins a protein to an antigen (in the case of pneumococcal vaccines, the protein is connected to unique polysaccharides from the surface of each of the pneumococcal serotypes). The protein helps improve the quality of the immune system response to the vaccine compared to the response to an unconjugated polysaccharide.

Last reviewed: July 26, 2022

The polysaccharide vaccine includes the different polysaccharides (chains of complex sugars) from different serotypes as the antigen. The conjugate vaccines have the polysaccharides for different serotypes attached (or conjugated) to a CMR197 carrier protein. The immune response to the PPSV23 vaccine is a T-cell independent immune response, while the immune response to PCV vaccination is a T-cell dependent response that produces memory B-cells and reduces carriage of the bacteria in the respiratory track. The PPSV23 does not reduce bacterial carriage.

Last reviewed: July 26, 2022

FDA licensed the first pneumococcal conjugate vaccine against seven serotypes (PCV7, Prevnar7, Pfizer) in 2000. A large clinical trial showed PCV7 reduced invasive disease caused by vaccine serotypes by 97%. Compared to unvaccinated children, children who received PCV7:

  • Had 20% fewer episodes of chest X-ray confirmed pneumonia
  • Had 7% fewer episodes of acute otitis media
  • Underwent 20% fewer tympanostomy tube placements

FDA licensed PCV13 based on studies comparing the serologic response of children who received PCV13 to those who received PCV7. Substantial evidence demonstrates that routine infant PCV7 and PCV13 vaccination reduces the carriage and transmission of vaccine serotypes.

Researchers conducted a randomized placebo-controlled trial (CAPiTA trial) in the Netherlands among approximately 85,000 adults 65 years or older from 2008 through 2013. This trial evaluated the clinical benefit of PCV13 in the prevention of pneumococcal pneumonia. The results of the CAPiTA trial demonstrated:

  • 46% efficacy against vaccine-type pneumococcal pneumonia
  • 45% efficacy against vaccine-type non-bacteremic pneumococcal pneumonia
  • 75% efficacy against vaccine-type invasive pneumococcal disease (IPD, i.e., bacteremia or meningitis)

FDA licensed PCV15 and PCV20 in 2021 based on studies comparing the serologic response of adults who received either PCV15 or PCV20 to those who received PCV13. These studies showed PCV15 and PCV20 induced antibody levels comparable to those induced by PCV13 and shown to be protective against invasive disease.

Last reviewed: July 26, 2022

According to CDC, more than 80% of healthy adults who receive PPSV23 develop antibodies against the serotypes contained in the vaccine that persist for at least 5 years. Older adults and people with some chronic illnesses or immunodeficiency may not respond as well and their antibody levels may decline more quickly.

Overall, the vaccine is 60% to 70% effective in preventing invasive pneumococcal disease caused by serotypes in the vaccine. PPSV23 shows less effectiveness among immunocompromised people; however, because of their increased risk of invasive pneumococcal disease, CDC recommends PPSV23 for people in these groups who receive PCV15. There has not been consensus regarding the ability of PPSV23 to prevent non-bacteremic pneumococcal pneumonia; however, recent observational studies reported 21%–46% effectiveness against PPSV23-type pneumococcal pneumonia when PPSV23 was given less than 5 years before illness onset.

Unlike conjugate vaccines, PPSV23 vaccination has not been shown to decrease nasal carriage of pneumococcal bacteria among those vaccinated.

Last reviewed: July 26, 2022

The recommendations for pneumococcal vaccination of children and adults vary depending upon the specific vaccines available and the age and medical or behavioral risk factors of potential recipients. CDC has summarized all of its recommendations at this site: www.cdc.gov/vaccines/vpd/pneumo/hcp/recommendations.html.

Last reviewed: July 26, 2022

S. pneumoniae bacteria are serotyped based on the polysaccharides in the outer capsule of the bacteria. Serotypes vary in how common they are and in what percentage of pneumococcal disease they cause.

Among the PCV vaccines, PCV13 includes serotypes: 1, 3, 4, 5, 6A, 6B, 7F, 9V, 14, 18C, 19A, 19F and 23F. PCV15 includes all PCV13 serotypes plus 22F and 33F. PCV20 includes all PCV15 serotypes plus 8, 10A, 11A, 12F, and 15B. PPSV23 vaccine does not contain serotype 6A or 19A, but contains 19 other serotypes present in PCV20, plus serotypes 2, 9N, 17F, and 20.

1 2 3 4 5 6A 6B 7F 8 9N 9V 10A 11A 12F 14 15B 17F 18C 19A 19F 20 22F 23F 33F
PCV13 x   x x x x x x     x       x     x x x     x  
PCV15 x   x x x x x x     x       x     x x x   x x x
PCV20 x   x x x x x x x   x x x x x x   x x x   x x x
PPSV23 x x x x x   x x x x x x x x x x x x   x x x x x
Last reviewed: July 26, 2022

PCV vaccines are recommended to be given first because this sequence provides the best immune response to both PCV and PPSV23 vaccines. An evaluation of immune response after a second pneumococcal vaccination administered 1 year after an initial dose showed that subjects who received PPSV23 as the initial dose had lower antibody responses after subsequent administration of PCV13 than those who had received PCV13 as the initial dose followed by a dose of PPSV23.

Last reviewed: July 26, 2022

In 2000, the first pneumococcal conjugate vaccine (PCV) was licensed in the U.S. This vaccine contained seven serotypes (4, 6B, 9V, 14, 18C, 19F, and 23F) of Streptococcus pneumoniae and became known as PCV7 (Prevnar by Wyeth, now Pfizer). Ten years later in February 2010, a new 13-valent product was licensed — PCV13 (Prevnar 13, Pfizer) — which added 6 new serotypes (1, 3, 5, 6A, 7F, and 19A). Together, these 13 serotypes account for the majority of invasive pneumococcal disease (IPD) in the U.S., including serotype 19A, which is the most common IPD-causing serotype in young children. In February 2010 ACIP recommended that healthcare providers transition from use of PCV7 to use of PCV13 for routine vaccination of children.

PCV7 was initially recommended for routine use in infants and children ages 2 through 59 months. The recommendations were expanded with the licensure of PCV13 to include vaccination of children age 60 through 71 months with underlying medical conditions, and also vaccination of older children, ages 6 through 18 years, with medical conditions placing them at increased risk of invasive pneumococcal disease.

Last reviewed: July 26, 2022

All infants should be given a primary series of PCV13, at ages 2, 4, and 6 months with a booster at age 12 to 15 months. Children who fall behind should be given catch-up vaccination through age 59 months, if otherwise healthy, or through age 71 months if they have certain underlying medical conditions.

For pneumococcal vaccination of children ages 2 through 5 years, see the CDC summary here: www.cdc.gov/vaccines/vpd/pneumo/hcp/who-when-to-vaccinate.html#children-2-5.

Last reviewed: July 26, 2022

A single dose of PCV13 should be given to children ages 6 –18 years who have not received PCV13 before and have anatomic or functional asplenia (including sickle cell disease), immunocompromising conditions (such as HIV infection), cochlear implant, or cerebrospinal fluid (CSF) leaks. Routine use of PCV13 is not recommended for healthy children 5 years of age or older.

When elective splenectomy, immunocompromising therapy, or cochlear implant placement is being planned, PCV13 and/or PPSV23 vaccination (as needed) should be completed at least 2 weeks before surgery or initiation of therapy. For people not vaccinated 2 weeks prior, vaccinate as soon as possible.

For a complete explanation of pneumococcal vaccination recommendations for ages 6 through 18 years, CDC has summarized the recommendations here: www.cdc.gov/vaccines/vpd/pneumo/hcp/who-when-to-vaccinate.html#children-6-18.

Last reviewed: July 26, 2022

All children should receive routine vaccination with PCV13 as age-appropriate. A child age 2 through 18 years should receive PPSV23 at least 8 weeks following the last recommended dose of PCV13 if they have any of the following conditions:

  1. alcoholism
  2. chronic liver disease, including cirrhosis
  3. chronic heart disease (e.g., congestive heart failure, cardiomyopathies), excluding hypertension
  4. chronic lung disease (including COPD and emphysema)
  5. diabetes mellitus
  6. candidate for or recipient of cochlear implant
  7. cerebrospinal fluid (CSF) leak
  8. functional or anatomic asplenia (e.g., splenectomy or congenital asplenia)
  9. sickle cell disease and other hemoglobinopathies
  10. congenital or acquired immunodeficiencies (e.g., B- (humoral) or T-lymphocyte deficiency, complement deficiencies (particularly C1, C2, C3, and C4), and phagocytic disorders (excluding chronic granulomatous disease)
  11. generalized malignancy
  12. HIV infection
  13. Hodgkin’s disease, leukemia, lymphoma, and multiple myeloma
  14. immunosuppression due to treatment with medication, including long-term systemic corticosteroids, and radiation therapy
  15. solid organ transplantation; for bone marrow transplantation, see www.cdc.gov/vaccines/hcp/acip-recs/general-recs/immunocompetence.html
  16. chronic renal failure or nephrotic syndrome
Last reviewed: July 26, 2022

All children 2-18 years who are at highest risk for serious pneumococcal infection (see categories 9 through 16 in related answer) should first be assessed and age-appropriately vaccinated with PCV13, if indicated. At least 8 weeks following completion of PCV13 vaccination, these children should get the first of 2 doses of PPSV23, spaced five years apart. Children with risk factors 1 through 8 above should get one dose of PPSV23.

Last reviewed: July 26, 2022

ACIP does not recommend routine PCV13 vaccination of healthy children 60 months of age or older. If there is a school requirement, the simplest solution is to give the child one dose of PCV13. However, health insurance may not pay for this dose. For more information on the ACIP recommendations for pneumococcal vaccination of children, go to CDC’s summary of pneumococcal vaccine recommendations: www.cdc.gov/vaccines/vpd/pneumo/hcp/who-when-to-vaccinate.html.

Last reviewed: July 26, 2022

No. Currently no data exist to indicate that people younger than 19 who smoke are at increased risk of pneumococcal disease.

Last reviewed: July 26, 2022

PPSV23 is not effective in children less than 24 months of age. PPSV23 given to children younger than 2 years old should not be considered part of the pneumococcal vaccination series. PCV13 should be administered as soon as the error is discovered. Any time the wrong vaccine is given, the parent/patient should be notified.

Last reviewed: July 26, 2022

Yes. Selective IgA deficiency is a B-cell immunodeficiency, so PPSV23 is indicated if the child is age 2 years or older and already age-appropriately vaccinated with PCV13. If the child were not fully vaccinated with PCV13, the recommendation would have been to give her any recommended doses of PCV13 first, followed by PPSV23 at least 8 weeks later. PCV15 and PCV20 are not recommended for use in children at this time.

Last reviewed: July 26, 2022

Two new pneumococcal conjugate vaccines (PCV15 and PCV20) are now recommended as pneumococcal vaccination options for all adults age 65 and older and for adults age 19 through 64 with certain medical conditions or other risk factors for pneumococcal disease; ACIP no longer recommends PCV13 for adults. When PCV15 is used routinely, it should be used in series with PPSV23 given one year later.

For adults eligible for pneumococcal vaccine as a result of age or a high-risk condition who have no or unknown history of pneumococcal conjugate vaccination, the same vaccination schedule options apply to all of them: either give one dose of PCV20 alone, or give a dose of PCV15 followed by a dose of PPSV23 one year later (with a minimum interval option of 8 weeks for people with immunocompromise, CSF leak, or cochlear implant). People age 19 through 64 with immunocompromising and non-immunocompromising underlying medical conditions and other risk factors for pneumococcal disease no longer have separate recommendations for different types of vaccines or numbers of doses.

Details of the recommendations can be found in the ACIP recommendations at www.cdc.gov/mmwr/volumes/71/wr/pdfs/mm7104a1-H.pdf. These recommendations are to be used in conjunction with CDC clinical considerations for the use of pneumococcal vaccines at: www.cdc.gov/vaccines/vpd/pneumo/hcp/recommendations.html.

Immunize.org has developed standing orders for pneumococcal vaccination of adults at www.immunize.org/catg.d/p3075.pdf.

Last reviewed: July 26, 2022

All people age 19 through 64 with the following medical conditions who have no history of pneumococcal vaccination or an unknown pneumococcal vaccination history should receive either a single dose of PCV20 alone or a dose of PCV15 followed by a dose of PPSV23 at least 1 year later. If using the PCV15 + PPSV23 series, clinicians can consider giving the dose of PPSV23 a minimum of 8 weeks later for more rapid protection against the serotypes unique to PPSV23 to people with CSF leak, cochlear implant, or immunocompromise (categories 7 through 17 below):

  1. cigarette smoking (does not include people who vape)
  2. alcoholism
  3. chronic liver disease, including cirrhosis
  4. chronic heart disease (e.g., congestive heart failure, cardiomyopathies), excluding hypertension
  5. chronic lung disease (including COPD and emphysema, and asthma)
  6. diabetes mellitus
  7. candidate for or recipient of cochlear implant
  8. cerebrospinal fluid (CSF) leak
  9. functional or anatomic asplenia (e.g., splenectomy or congenital asplenia)
  10. sickle cell disease and other hemoglobinopathies
  11. congenital or acquired immunodeficiencies (e.g., B- [humoral] or T-lymphocyte deficiency, complement deficiencies [particularly C1, C2, C3, and C4], and phagocytic disorders [excluding chronic granulomatous disease])
  12. generalized malignancy
  13. HIV infection
  14. Hodgkin disease, leukemia, lymphoma, and multiple myeloma
  15. immunosuppression due to treatment with medication, including long-term systemic corticosteroids, and radiation therapy
  16. solid organ transplantation; for bone marrow transplantation; see www.cdc.gov/vaccines/hcp/acip-recs/general-recs/immunocompetence.html
  17. chronic renal failure or nephrotic syndrome

Public health authorities working with Alaska Natives and American Indians may provide additional guidance for individuals in those communities where the overall risk of invasive pneumococcal disease is increased.

Last reviewed: July 26, 2022

For adults 65 years and older with no prior pneumococcal vaccination or whose previous vaccination history is unknown, you have two options:

  • One dose of PCV20 alone, or
  • One dose of PCV15 followed by a dose of PPSV23 one year later
Last reviewed: July 26, 2022

Under the new recommendations, adults who have ever had at least one dose of PPSV23 do not need another dose of PPSV23 after turning 65. They have two options:

  • One dose of PCV20, or
  • One dose of PCV15
Last reviewed: July 26, 2022

The patient should be vaccinated at least 2 weeks before the splenectomy, if feasible. If not, vaccinate as soon as possible. Depending upon products available, he has two options:

  • One dose of PCV20 alone, or
  • One dose of PCV15 followed by a dose of PPSV23 (consider giving PPSV23 as soon as 8 weeks later)

CDC recommends that, if using the PCV15 and PPSV23 series, a minimum interval of 8 weeks can be considered for adults with an immunocompromising condition (including asplenia), cochlear implant, or cerebrospinal fluid leak to minimize the risk for IPD caused by serotypes unique to PPSV23 in these vulnerable groups.

Last reviewed: July 26, 2022

People with anatomic asplenia should follow the same recommendations as described for people with immunocompromising conditions. CDC currently recommends that people with immunocompromising conditions who have already received PCV13 should continue to follow the PPSV23 pneumococcal vaccination schedule recommended for people who have had PCV13. Adults with immunocompromising conditions who are younger than age 65 and who have already had PCV13 should receive one dose of PPSV23 at least 8 weeks after the dose of PCV13, then a second dose of PPSV23 at least 5 years later. If the second dose is administered before the age of 65, then a final (3rd) dose of PPSV23 is recommended at least 5 years later, on or after the 65th birthday.

If PPSV23 is due but is unavailable, and PCV20 is available, PCV20 may be given at the visit. No further doses of any type of pneumococcal vaccine are recommended after PCV20 is given.

Last reviewed: July 26, 2022

CDC says that PCV20 may be used instead of PPSV23 if PPSV23 is unavailable. If your clinic has PCV20 but does not have PPSV23 available at the vaccination visit, do not miss the opportunity to vaccinate. Give a single dose of PCV20.

No future doses of PPSV23 or any other pneumococcal vaccine are currently recommended following a dose of PCV20, even if the patient is younger than age 65.

Last reviewed: July 26, 2022

Nothing. People who have had PCV13 and PPSV23 after the 65th birthday are not currently recommended to receive any additional doses of pneumococcal vaccine.

Last reviewed: July 26, 2022

The patient may be given one dose of PCV20 or one dose of PCV15. CDC does not recommend additional doses of PPSV23 for a person who received a dose of PPSV23 on or after age 65 years, regardless of the interval since vaccination.

Last reviewed: July 26, 2022

No. All adults age 65 years and older without a prior PCV vaccination are now routinely recommended to receive either PCV20 alone or a 2-dose series of PCV15 followed by PPSV23 one year later. PCV13 is no longer recommended for adults.

Last reviewed: July 26, 2022

No. All adults for whom pneumococcal vaccination is recommended due to age (65 or older) or an underlying condition (age 19 through 64) are now recommended to receive a conjugate vaccine. Prior recipients of PPSV23 may now receive either PCV20 or PCV15 at least 1 year after the dose of PPSV23. Adults who have had PCV13 should receive PPSV23 as recommended for them before the introduction of PCV15 and PCV20, based on age or risk factors, as described elsewhere.

Last reviewed: July 26, 2022

Yes. Adalimumab is a potent anti-inflammatory drug that blocks the activity of tumor necrosis factor (TNF). Adalimumab is considered immunosuppressive because serious infections have been reported in people taking the drug, including tuberculosis and infections caused by viruses, fungi, or bacteria. A person taking adalimumab or other drugs that affect TNF activity (such as infliximab [Remicade], certolizumab pegol [Cimzia], golimumab [Simponi], or etanercept [Enbrel]) should be considered to have immunosuppression and receive either PCV20 alone or a 2-dose series of PCV15 followed by PPSV23. Clinicians can consider giving PPSV23 as soon as 8 weeks after PCV15 in this case, in order to accelerate protection against strains of pneumococcus unique to PPSV23.

Last reviewed: July 26, 2022

No. If there is no longer a CSF leak, neither vaccine is recommended, unless there is another risk factor for invasive pneumococcal disease or an age-based indication.

Last reviewed: July 26, 2022

No. Beta thalassemia minor is a hemoglobinopathy, but compared to sickle cell disease, these patients have less risk for functional asplenia, and, therefore a reduced risk for invasive pneumococcal disease.

Last reviewed: July 26, 2022

No. However, adults who received PCV13 should complete their recommended PPSV23 vaccination 1 year after PCV13. If PPSV23 is not available when the vaccination is due, but PCV20 is available, PCV20 may be given.

Last reviewed: July 26, 2022

What you describe is an excellent strategy for administration of pneumococcal vaccines to people age 65 years and older. ACIP does not define “one year” but this is assumed to be one calendar year. Receiving PPSV23 a few days or weeks earlier than one calendar year after PCV13 or PCV15 is not a medical problem. However, it could be a problem for reimbursement since Medicare will only pay for both a PCV vaccine and a PPSV23 vaccine if they are given at least 11 months apart. Private insurance may have similar rules. Here is the wording from the Centers for Medicare and Medicaid (CMS): “An initial pneumococcal vaccine may be administered to all Medicare beneficiaries who have never received a pneumococcal vaccine under Medicare Part B. A different, second pneumococcal vaccine may be administered 1 year after the first vaccine was administered (i.e., 11 full months have passed following the month in which the last pneumococcal vaccine was administered).”

Last reviewed: July 26, 2022

Studies have shown that administering a pneumococcal conjugate vaccine first leads to a better immune response to serotypes common to both vaccines when the polysaccharide vaccine (PPSV23) is given at a later date. For this reason, the Advisory Committee on Immunization Practices (ACIP) recommends that pneumococcal vaccine-naive adults receive pneumococcal conjugate vaccines either alone (PCV20) or first in a sequence (PCV15 first, followed by PPSV23). A provider who stocks only PPSV23 should consider referring such patients elsewhere to receive a conjugate vaccine, if feasible. A patient due for a conjugate vaccine who receives PPSV23 first may receive either the PCV15 or PCV20 vaccine at least one year later.

Last reviewed: July 26, 2022

For people with immunosuppression, ACIP recommends 1 dose of PCV20 or one dose of PCV15 followed by a dose of PPSV23 one year later (can consider a minimum 8-week interval for immunocompromised adults). Meningococcal serogroup B vaccine (MenB) is not specifically recommended for immunosuppressed people. However, a patient who is age 16 through 23 years and immunosuppressed may receive routine MenB vaccination of either a 2-dose series of Bexsero (GSK) 4 weeks apart, or a 3-dose series of Trumenba (Pfizer) at 0, 1 month, and 6 months apart.

Last reviewed: July 26, 2022

A CDC study has shown a small increased risk for febrile seizures during the 24 hours after a child receives the inactivated influenza vaccine at the same time as the PCV13 vaccine or DTaP vaccine. However, the risk of febrile seizure with any combination of these vaccines is small and ACIP recommends giving these vaccines at the same visit if indicated. The risk for febrile seizures in children who received PCV15 or PCV20 concurrently with an influenza vaccine has not been studied. See www.cdc.gov/vaccinesafety/concerns/febrile-seizures.html for more information about febrile seizures after vaccination.

Last reviewed: September 10, 2023

Mesalamine (mesalazine) is a non-steroidal anti-inflammatory drug. It is not immunosuppressive, so it’s use would not place a person at increased risk of invasive pneumococcal disease.

Last reviewed: July 26, 2022

Multiple sclerosis is not a contraindication to any vaccine, including pneumococcal vaccines.

Last reviewed: July 26, 2022

Studies done in children showed possible interference with the response to PCV7 when PCV7 and MenACWY-D (Menactra, Sanofi Pasteur) were given simultaneously. For this reason, CDC also recommended that children not receive PCV13 and Menactra at the same visit. This recommendation does not apply to any other brand of MenACWY, including MenACWY-CRM (Menveo, GSK) or MenACWY-TT (MenQuadfi, Sanofi Pasteur). MenQuadfi is gradually replacing Menactra.

At this time, there are no data to support a similar formal recommendation for separating PCV and Menactra for adults. However, to be prudent, if Menactra is the only brand available, you should follow the same principle as for children and administer it 4 weeks after the PCV. Alternatively, if feasible, it would be simpler to administer a different MenACWY product at the same time as the PCV (MenQuadfi or Menveo).

Due to the extreme risk of invasive pneumococcal disease in people without a functional spleen, if Menactra is inadvertently administered to an asplenic person within 4 weeks of a dose of PCV (in either order), repeat the dose of PCV at least 4 weeks after whichever vaccine was administered second.

Last reviewed: July 26, 2022

In the absence of “generalized malignancy” (which is generally considered to mean disseminated cancer) or immunosuppression, a recent history of prostate cancer surgery alone is not an indication for pneumococcal vaccination among people younger than 65 years.

Last reviewed: July 26, 2022

Because pneumococcal recommendations have changed over the years, providers should not assume which pneumococcal vaccines a patient has received. Ideally, providers and patients should try to verify which vaccines were received, including by checking medical records and the jurisdiction’s immunization information system (immunization registry) where the patient was likely vaccinated.

Per the CDC “General Best Practices Guidelines for Immunization”, self-reported doses of influenza and PPSV23 are acceptable. All other vaccines must be documented with a written, dated record. This means that if a patient reasonably recalls receiving a pneumococcal polysaccharide vaccination after turning 65, you may accept that as a history of PPSV23 and administer either PCV15 or PCV20.

Alternatively, if vaccination records cannot be obtained, and the patient is uncertain whether they received PCV13 or PPSV23, you may choose to classify the patient as having an unknown vaccination history and administer either PCV20 alone or PCV15 followed by PPSV23 one year later.

Last reviewed: July 26, 2022

In 2008, ACIP reviewed evidence indicating that asthma is an independent risk factor for pneumococcal disease among adults. ACIP also reviewed evidence demonstrating an increased risk of invasive pneumococcal disease among smokers. Consequently, ACIP includes both asthma and cigarette smoking as indications for pneumococcal vaccination among adults age 19 through 64 years. People with these conditions should receive either a single dose of PCV20 alone, or a dose of PCV15 followed one year later by PPSV23. If they have already received PPSV23, but have not had a conjugate vaccine, they should receive either a single dose of PCV20 or a single dose of PCV15 at least one year following their dose of PPSV23.

Last reviewed: July 26, 2022

No. ACIP does not identify people who use smokeless tobacco products or vaping as being at increased risk for invasive pneumococcal disease or as being in a risk group recommended for vaccination.

Last reviewed: July 26, 2022

No, unless chronic lung disease is present, which puts them at increased risk of pneumococcal disease. PCV20 alone or PCV15 followed one year later by PPSV23 is recommended for current smokers of cigarettes age 19 through 64 years (see www.cdc.gov/mmwr/volumes/71/wr/pdfs/mm7104a1-H.pdf).

Last reviewed: July 26, 2022

No. ACIP does not designate people who smoke marijuana, but not cigarettes, as being in a risk group for vaccination. ACIP has not been presented evidence of an increased risk of pneumococcal disease among regular marijuana smokers.

Last reviewed: July 26, 2022

In the pneumococcal vaccine recommendations for adults that were updated January 28, 2022, the many risk groups for pneumococcal disease were combined into one group with regard to vaccine recommendations. All are recommended to receive either PCV20 alone or PCV15 followed by PPSV23 one year later. ACIP no longer recommends the use of PPSV23 alone for any adult. Cigarette smokers age 19 through 64 who received PPSV23 in the past may now receive a dose of either PCV20 or PCV15 at least one year after their dose of PPSV23.

Last reviewed: July 26, 2022

Yes. Pneumococcal vaccination is recommended for adults age 19 through 64 years with all types of asthma. Available data do not indicate that asthma alone increases the risk of invasive pneumococcal disease among people younger than age 19 years, so pneumococcal vaccination is not currently recommended for people with asthma who are younger than 19.

Last reviewed: July 26, 2022

No. Obstructive sleep apnea alone is not an indication for pneumococcal vaccination. However, people with obstructive sleep apnea often have other pulmonary conditions (such as chronic obstructive pulmonary disease) that would put them at increased risk for invasive pneumococcal disease, for which they should be vaccinated.

Last reviewed: July 26, 2022

Yes. People with HIV infection are at high risk of pneumococcal disease. Adults 19 and older should be vaccinated with PCV20 alone or with PCV15 followed by PPSV23 one year later. If using a combination of PCV15 followed by PPSV23, consider using a minimum interval of at least 8 weeks between doses if more rapid protection from serotypes unique to PPSV23 is desired.

Last reviewed: July 26, 2022

Lupus alone is not an indication for pneumococcal vaccination. However, immunosuppressive medication that may be used to treat lupus could create an indication for administering pneumococcal vaccines. Also, certain complications of lupus (such as nephrotic syndrome) make a person a candidate for pneumococcal vaccination. If pneumococcal vaccination is indicated, administer either PCV20 alone or PCV15 followed by PPSV23 one year later. If the patient is immunosuppressed and is receiving a combination of PCV15 followed by PPSV23, consider using a minimum interval of at least 8 weeks between doses if more rapid protection from serotypes unique to PPSV23 is desired.

Last reviewed: July 26, 2022

With the 2022 published ACIP recommendations for adults, people age 19 or older with diabetes should receive either PCV20 alone or a series of PCV15 followed in one year by PPSV23. No further doses are recommended. People with diabetes who are age 19 through 64 and have already received one dose of PPSV23 may receive either a dose of PCV20 or PCV15 alone; no further doses of PPSV23 are recommended. People with diabetes who have already received PCV13 and have received a PPSV23 vaccination since turning 65 are not recommended to receive any additional doses of pneumococcal vaccine.

Last reviewed: July 26, 2022

No.

Last reviewed: July 26, 2022

Adult dialysis patients who have not previously received pneumococcal vaccination should receive either PCV20 alone or a series of PCV15 followed by PPSV23 in one year. No further pneumococcal vaccines are recommended.

Last reviewed: July 26, 2022

ACIP’s current pneumococcal vaccination recommendations for adults do not specifically address people with a history of PCV7 in childhood. CDC’s clinical considerations address a history of PCV13 and/or PPSV23. It is reasonable to ignore the remote history of PCV7 in childhood when evaluating and offering vaccination with PCV20 alone or PCV15 in series with PPSV23 to a younger adult at high risk for whom pneumococcal vaccination is indicated. This guidance may be updated if ACIP addresses this specifically in the future.

Last reviewed: July 26, 2022

Yes. Under the new ACIP recommendations published in January 2022, adults age 19 through 64 who have already received a dose of PCV13 (as previously recommended for those with immunocompromising conditions [including asplenia], CSF leak, or cochlear implant) should complete the immunization schedule that was recommended before the introduction of PCV15 and PCV20.

Adults age 19 through 64 who have immunocompromising conditions, a CSF leak, or a cochlear implant and who have already received a dose of PCV13 should receive a dose of PPSV23 at least 8 weeks later. Those who are immunocompromised should then receive a second dose of PPSV23 at least 5 years following the first dose; if younger than 65 at the time of dose 2, they should receive a third dose of PPSV23 at least 5 years later and after turning 65.

If PPSV23 is unavailable when vaccination is due and PCV20 is available, PCV20 may be used. If PCV20 is administered, no additional doses of pneumococcal vaccine are recommended.

Last reviewed: July 26, 2022

That is not necessary. Although PPSV23 is recommended, CDC has stated that PCV20 may be used if PPSV23 is unavailable.

Last reviewed: July 26, 2022

At this time, ACIP does not recommend revaccination with PPSV23 for adults younger than 65 who are at the highest risk of pneumococcal disease (including those with asplenia) who receive PCV15 (Vaxneuvance) followed by PPSV23.

If an adult patient with asplenia receives PCV13 (Prevnar 13) followed by PPSV23, ACIP recommends continuing the previously recommended schedule for patients with immunocompromising conditions (including asplenia) who receive that vaccine combination. In that case, the patient would be revaccinated with PPSV23 at least 5 years following the first dose. If dose 2 is administered when the patient is younger than 65, then dose 3 is due at least 5 years later and after the patient turns 65.

If an adult patient with asplenia receives a dose of PCV20, ACIP does not recommend further doses of any pneumococcal vaccine.

Last reviewed: July 26, 2022

A second PPSV23 given 5 years after the first dose is recommended for people age 19 through 64 years who were vaccinated with PCV13 and PPSV23 and who have one of the following:

  • functional or anatomic asplenia (including persons with sickle cell disease or splenectomy patients)
  • chronic renal failure (including dialysis patients) or nephrotic syndrome
  • immunocompromise (including HIV infection)
  • leukemia, lymphoma, Hodgkin disease, multiple myeloma, generalized malignancy
  • immunosuppressive therapy (including long-term systemic corticosteroids or radiation therapy)
  • solid organ transplant
Last reviewed: July 26, 2022

Yes, but only if they have already received PCV13. If they have not received any PCV product, or their history of PCV vaccination is unknown, they may receive a single dose of either PCV15 or PCV20. If they have already received either PCV20 or PCV15, then no additional PPSV23 doses are needed.

Last reviewed: July 26, 2022

No. ACIP does not recommend revaccination with PPSV23 for any adult who has received a dose of PPSV23 after turning 65. The patient may, however, receive either PCV15 or PCV20 if they have not already received PCV13.

Last reviewed: July 26, 2022

Yes. There are more than 100 known serotypes of pneumococcus. Infection with one serotype does not necessarily produce immunity to other serotypes. As a result, if the person is a candidate for vaccination, they should receive it even after one or more episodes of invasive pneumococcal disease.

Last reviewed: July 26, 2022

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