Ask the Experts: Pneumococcal: Recommendations for Adults

Results (39)

ACIP has made a series of changes in its recommendations for pneumococcal vaccination of adults since 2022 in response to the licensure of new pneumococcal conjugate vaccines (PCVs). In January 2022, CDC published recommendations for PCV15 (Vaxneuvance, Merck) and PCV20 (Prevnar 20, Pfizer) 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 stopped recommending PCV13 (Prevnar 13, Pfizer) for adults; however, CDC clinical guidance allows for its use in rare circumstances if only PCV13 is accessible and the patient would otherwise be unvaccinated. When PCV15 is used routinely, it should be used in series with 23-valent pneumococcal polysaccharide vaccine (PPSV23, Pneumovax, Merck) given one year later. 

In June 2024, ACIP recommended PCV21 (Capvaxive, Merck) as an option in all situations where PCV is recommended for adults. As with PCV20, PPSV23 is not recommended following PCV21. 

In October 2024, ACIP recommended that routine immunization of all adults with a PCV begin at age 50 years, rather than age 65 years. This change was made to address the substantial amount of preventable invasive pneumococcal disease (IPD) among adults age 50 through 64.   

Adults 19 through 49 years eligible for pneumococcal vaccination as a result of a high-risk condition who have no or unknown history of PCV should receive one dose of PCV20 or PCV21 alone, or a dose of PCV15 followed by a dose of PPSV23 one year later (with a minimum interval option of 8 weeks for people with an immunocompromising condition, cochlear implant, or cerebrospinal fluid leak).  

The current CDC guidance for the use of pneumococcal vaccines in adults are outlined in this job aid from CDC: www.cdc.gov/pneumococcal/downloads/Vaccine-Timing-Adults-JobAid.pdf.  

Immunize.org has standing orders for pneumococcal vaccination of adults for all PCV options and PPSV23 (if indicated) at:  www.immunize.org/catg.d/p3075.pdf. 

Last reviewed: November 13, 2024

Lowering the age for routine PCV use in adults from 65 to 50 years was intended to address the substantial burden of preventable invasive pneumococcal disease (IPD) and pneumococcal pneumonia in people age 50 through 64 years. Despite long-standing risk-based recommendations for pneumococcal vaccination of adults age 19 through 64 at increased risk of IPD, by 2022, just 23% of this target group had received at least one adult pneumococcal vaccination, according to CDC’s National Health Interview Survey. In addition, according to CDC surveillance data, by age 50, the rate of IPD among Black adults is higher than the rate in the general population of the United States by age 65. Finally, the newer PCV products protect against a substantially larger proportion of pneumococcal serotypes responsible for IPD in adults, compared to PCV13. ACIP members expressed their hope that expanding the simple age-based recommendation to give PCV at age 50 would increase access to and administration of PCV, especially among unvaccinated people at increased risk of IPD. 

Last reviewed: November 13, 2024

It is likely. Effectiveness of pneumococcal polysaccharide vaccine (PPSV23) begins waning significantly after about 5 years. While current pneumococcal conjugate vaccines (PCVs) are expected to remain effective longer than that, for at least several years, a future PCV dose may be needed by those vaccinated at younger ages to boost protection later in life. When ACIP voted to lower the routine PCV vaccination age to 50, the committee took into consideration that an additional dose, perhaps 10 or 15 (or more) years later, may be needed. In coming years, ACIP will periodically review any evidence of waning protection, evaluate future pneumococcal vaccine products, and make recommendations for revaccination of older adults when needed.

Last reviewed: November 13, 2024

All people age 19 through 49 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 or PCV21 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 immunocompromising condition, cochlear implant, or cerebrospinal fluid (CSF) leak. The conditions are:

  • Alcoholism or cigarette smoking
  • CSF leak
  • Chronic heart disease, including congestive heart failure and cardiomyopathies, excluding hypertension
  • Chronic liver disease
  • Chronic lung disease, including chronic obstructive pulmonary disease, emphysema, and asthma
  • Cochlear implant (including those preparing for cochlear implant)
  • Diabetes mellitus
  • Decreased immune function from disease or drugs (immunocompromising conditions), including:
    • Chronic renal failure or nephrotic syndrome
    • Congenital or acquired asplenia, or splenic dysfunction
    • Congenital or acquired immunodeficiency, including B-(humoral) or T-lymphocyte deficiency; complement deficiencies, particularly C1, C2, C3, and C4 deficiency; and phagocytic disorders (excluding chronic granulomatous disease)
    • Diseases or conditions treated with immunosuppressive drugs or radiation therapy, including Hodgkin disease, leukemias, lymphomas, malignant neoplasms, and solid organ transplant
    • HIV infection

For details of vaccination following hematopoietic stem cell transplantation, see www.cdc.gov/vaccines/hcp/imz-best-practices/altered-immunocompetence.html

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: November 13, 2024

For adults 50 years and older with no prior pneumococcal vaccination or whose previous vaccination history is unknown, you have two options: 

  • One dose of PCV20 or PCV21 alone, or
  • One dose of PCV15 followed by a dose of PPSV23 one year later (if the patient has an immunocompromising medical condition, cochlear implant or cerebrospinal fluid leak consider giving PPSV23 as soon as 8 weeks later).
Last reviewed: November 13, 2024


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Last reviewed: November 13, 2024

CDC recommends that adults who have ever had at least one dose of PPSV23 do not need another dose of PPSV23. They should receive one dose of any of the 3 recommended vaccine options: PCV15, PCV20, or PCV21, at least one year after their PPSV23 dose.

Last reviewed: November 13, 2024

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 three options:

  • One dose of PCV20 or PCV21 alone, or
  • One dose of PCV15 followed by a dose of PPSV23

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 splenectomy), cochlear implant, or cerebrospinal fluid leak.

Last reviewed: November 13, 2024

CDC currently recommends that people age 50 years or older who have ever received PCV13 and who have also had 1 dose of PPSV23 before turning age 65 should receive either PCV20 or PCV21 at least 5 years after their most recent pneumococcal vaccination.

Last reviewed: November 13, 2024

Administer the PCV20. CDC recommendations were updated in October 2024 to state that recipients of PCV13 should receive PCV20 or PCV21 at least one year after the dose of PCV13. CDC no longer recommends PPSV23 as an option following PCV13. PPSV23 is only recommended for adults who receive a dose of PCV15 and have never had a dose of PPSV23 before.

No future doses of any pneumococcal vaccine are currently recommended following a dose of PCV20 or PCV21.

Last reviewed: November 13, 2024

People who have had PCV13 and PPSV23 after the 65th birthday are not routinely recommended to receive additional doses of pneumococcal vaccine; however, they may receive a dose of PCV20 or PCV21 at least 5 years after their most recent pneumococcal vaccination based on shared clinical decision-making. The benefit of PPSV23 wanes after about 5 or more years. Considerations for PCV20 or PCV21 in this situation include the patient’s overall health and risk of pneumococcal disease, their desire to be protected, and time since last pneumococcal vaccination.

Last reviewed: November 13, 2024

The patient may be given one dose of PCV20 or PCV21. CDC estimates that PCV20 targets serotypes that cause approximately 54% of invasive pneumococcal disease (IPD) in people age 65 years and older in the United States and that PCV21 targets serotypes that cause approximately 85% of IPD cases in that U.S. age group. In some parts of the Western United States, pneumococcal serotype 4 is known to be responsible for more than 30% of IPD cases and state or local public health officials may advise healthcare providers that a product that covers serotype 4 (PCV20) may provide broader coverage than national estimates suggest. CDC does not recommend additional doses of PPSV23.

Last reviewed: November 13, 2024

No. All adults age 50 years and older without a prior PCV vaccination are now routinely recommended to receive PCV20 or PCV21 alone or a 2-dose series of PCV15 followed by PPSV23 one year later. People in this age group with an immunocompromising condition, cochlear implant, or cerebrospinal fluid leak who are given PCV15 may receive PPSV23 as little as 8 weeks later. PCV13 is no longer recommended for adults; however, CDC states that in rare situations where no PCV15, PCV20, or PCV21 is available and a patient is otherwise unlikely to be vaccinated at all, an available dose of PCV13 may be used.

Last reviewed: November 13, 2024

No. All adults for whom pneumococcal vaccination is recommended due to age (50 or older) or an underlying condition (age 19 through 49) are now recommended to receive a pneumococcal conjugate vaccine. When PCV20 or PCV21 is given, no further pneumococcal vaccination is recommended. If PCV15 is given to an adult, PPSV23 is recommended one year later (minimum interval of 8 weeks). Prior recipients of PPSV23 alone may now receive PCV15, PCV20, or PCV21 at least 1 year after the dose of PPSV23.

Last reviewed: November 13, 2024

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 PCV20 or PCV21 alone or 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: November 13, 2024

No. If there is no longer a CSF leak, pneumococcal conjugate vaccine is not recommended, unless there is another risk factor for invasive pneumococcal disease or an age-based indication.

Last reviewed: November 13, 2024

No. Beta thalassemia minor is a hemoglobinopathy, but compared to sickle cell disease, these patients have less risk for functional asplenia, and therefore do not have a significantly increased risk of invasive pneumococcal disease.

Last reviewed: November 13, 2024

Adults that received PCV13 should complete the pneumococcal series with PCV20 or PCV21 vaccination at least 1 year after PCV13. PCV15 and PPSV23 are not recommended in this situation.

Last reviewed: November 13, 2024

What you describe is a good strategy for administration of the 2-dose pneumococcal vaccine series of PCV15 and PPSV23 to people age 50 years and older if you prefer not to complete their PCV vaccination with a single dose of either PCV20 or PCV21. 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 PCV15 is not a medical problem. However, it could be a problem for reimbursement since Medicare will only pay for both a PCV15 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: November 13, 2024

Studies have shown that administering the pneumococcal conjugate vaccine (PCV) 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, CDC recommends that pneumococcal vaccine-naive adults receive PCVs either alone (PCV20, PCV21) or first in a sequence (PCV15 first, followed by PPSV23). A provider who stocks only PPSV23 should consider purchasing a recommended PCV or referring patients elsewhere to receive a PCV, if feasible. A patient due for PCV who inadvertently receives PPSV23 first should receive PCV15, PCV20, or PCV21 vaccine at least one year later.

Last reviewed: November 13, 2024

For people with immunosuppression, ACIP recommends 1 dose of PCV20 or PCV21 alone or one dose of PCV15 followed by a dose of PPSV23 one year later (immunocompromised adults may receive PPSV23 with a minimum 8-week interval after PCV15). 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 with a 3-dose series of either Bexsero (GSK) or Trumenba (Pfizer).

Last reviewed: November 13, 2024

No. Mesalamine (mesalazine) is a non-steroidal anti-inflammatory drug. It is not immunosuppressive, so its use would not place a person at increased risk of invasive pneumococcal disease.

Last reviewed: November 13, 2024

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

People with multiple sclerosis may be on immunosuppressive medication. If so, immunosuppressed people should receive PCV20 or PCV21 alone or PCV15 followed by PPSV23 a minimum of 8 weeks later.

For additional details, see  www.cdc.gov/pneumococcal/hcp/vaccine-recommendations/risk-indications.html.  

Last reviewed: November 13, 2024

Studies done in children showed possible interference with the response to PCV7 when PCV7 and the Menactra brand of MenACWY-D (by Sanofi) were given simultaneously. For this reason, Menactra was recommended not to be given at the same time as PCV. However, Menactra is no longer available, so this is no longer a consideration.

Available brands of MenACWY, including MenACWY-CRM (Menveo, GSK), MenACWY-TT (MenQuadfi, Sanofi), as well as the pentavalent MenABCWY (Penbraya, Pfizer), may be administered at the same time or any time before or after any pneumococcal vaccine.

Last reviewed: November 13, 2024

In the absence of immunosuppressive treatment, a recent history of prostate cancer surgery alone is not an indication for pneumococcal vaccination among people younger than 50 years. 

Last reviewed: November 13, 2024

Because pneumococcal recommendations have changed over the years, providers should generally avoid assuming 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 PPSV23 after turning 65, you may accept that as a history of PPSV23 and administer a recommended pneumococcal conjugate vaccine option (PCV20, or PCV21).

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 or PCV21 alone or PCV15 followed by PPSV23 one year later. When giving the PCV15 and PPSV23 series to a patient with an immunocompromising condition, cochlear implant, or cerebrospinal fluid leak, an 8-week minimum interval between PCV15 and PPSV23 may be considered.

Last reviewed: November 13, 2024

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 49 years. People with these conditions should receive either a single dose of PCV20 or PCV21 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 a single dose of a recommended pneumococcal conjugate vaccine (PCV15, PCV20, or PCV21) at least one year following their dose of PPSV23.

Last reviewed: November 13, 2024

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: November 13, 2024

No, unless chronic lung disease is present, which puts them at increased risk of pneumococcal disease. PCV20 or PCV21 alone or PCV15 followed one year later by PPSV23 is recommended for current smokers of cigarettes age 19 through 49 years (see  www.cdc.gov/mmwr/volumes/71/wr/pdfs/mm7104a1-H.pdf). 

Last reviewed: November 13, 2024

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: November 13, 2024

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 respect to vaccine recommendations. All are now recommended to receive PCV20 or PCV21 alone or PCV15 followed by PPSV23 one year later. ACIP no longer recommends the use of PPSV23 alone for any adult. Cigarette smokers too young for routine age-based vaccination recommendations who received PPSV23 alone in the past may now receive a dose of any recommended pneumococcal conjugate vaccine option (PCV15, PCV20, or PCV21) at least one year after their dose of PPSV23.

Last reviewed: November 13, 2024

Yes. Pneumococcal vaccination is recommended for adults age 19 through 49 years with all types of asthma.

Among children age 2 through 18 years, only those with moderate persistent or severe persistent asthma (regardless of high-dose oral corticosteroids use) should be evaluated for additional pneumococcal vaccine doses beyond the routine age-based schedule. Specific recommendations depend on age and the recipient’s specific pneumococcal vaccination history, including prior doses of any pneumococcal vaccine except PCV7. Prior doses of PCV7 may be ignored for the purposes of determining doses due now.

Last reviewed: November 13, 2024

No. Obstructive sleep apnea alone is not an indication for pneumococcal vaccination. However, people with obstructive sleep apnea may 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: November 13, 2024

Yes. People with HIV infection are at high risk of pneumococcal disease. The pneumococcal vaccination recommended depends on the patient’s age and prior pneumococcal vaccines received. See CDC’s information about risk-based recommendations for pneumococcal vaccination: www.cdc.gov/pneumococcal/hcp/vaccine-recommendations/risk-indications.html.  

The CDC PneumoRecs VaxAdvisor mobile app can be helpful for evaluating the needs of a specific patient. You can learn more and access the app here: www.cdc.gov/pneumococcal/hcp/vaccine-recommendations/app.html.  

Last reviewed: November 13, 2024

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 or PCV21 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: November 13, 2024

Recommendations vary among adults depending upon age, pneumococcal conjugate (PCV) or polysaccharide (PPSV) vaccination history (including PCV13, PCV15, PCV20, PCV21, and PPSV23), and pneumococcal vaccine products available:

  • Adults age 19 or older with diabetes and no history of receiving any pneumococcal vaccination as an adult should receive either PCV20 or PCV21 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 49 and have already received one dose of PPSV23 may receive one dose of any of the currently recommended PCV options (PCV15, PCV20, or PCV21) one year after the dose of PPSV23; no further doses of PPSV23 are recommended. 
  • People with diabetes and age 50 or older who received PCV13 and PPSV23 before age 50, should receive one dose of PCV20 or PCV21. PCV20 or PCV21 should be given at least 5 years after the last pneumococcal vaccination.  
  • People with diabetes who received PCV13 at any point and have received a PPSV23 vaccination since turning 65 are not routinely recommended to receive any additional doses of pneumococcal vaccine. However, they have the option to receive a dose of PCV20 or PCV21 at least 5 years after their most recent pneumococcal vaccination on the basis of shared clinical decision-making, based upon their risk of pneumococcal disease and desire for additional protection. 
Last reviewed: November 13, 2024

No.

Last reviewed: November 13, 2024

Recommendations for adult dialysis patients vary by age and pneumococcal conjugate (PCV) or polysaccharide (PPSV23) vaccination history:

  • Adult dialysis patients who have not previously received pneumococcal vaccination should receive either PCV20 or PCV21 alone or a series of PCV15 followed by PPSV23 at least 8 weeks later. No further pneumococcal vaccines are recommended. 
  • Adult dialysis patients who are age 19 through 49 and have already received one dose of PPSV23 may receive one dose of any currently recommended PCV (PCV15, PCV20, or PCV21) one year after the dose of PPSV23; no further doses of PPSV23 are recommended. 
  • Adult dialysis patients who are 50 or older and who have received PCV13 and PPSV23 in the past should receive one dose of PCV20 or PCV21 at least 5 years after the last pneumococcal vaccination.  
  • Adult dialysis patients who received PCV13 at any point and also received a PPSV23 vaccination after turning 65 are not routinely recommended to receive any additional doses of pneumococcal vaccine. They have the option to receive a dose of PCV20 or PCV21 at least 5 years after their most recent pneumococcal vaccination on the basis of shared clinical decision-making, based upon their risk of pneumococcal disease and desire for additional protection. 
Last reviewed: November 13, 2024

CDC’s guidance is to ignore the remote history of PCV7 and evaluate the patient as if he has never had pneumococcal vaccination. The patient should receive PCV20 or PCV21 alone or PCV15 in series with PPSV23 given at least one year later. If using PCV15, and if the high-risk condition is immunocompromising or if the patient has a cochlear implant or cerebrospinal fluid leak, you may consider administering the PPSV23 as soon as 8 weeks after PCV15.

Last reviewed: November 13, 2024

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