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Pneumococcal Vaccines

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Pneumococcal Vaccines

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Disease Issues
What causes pneumococcal disease?
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.
How does pneumococcal disease spread?
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.
What are the types of invasive pneumococcal disease?
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.
How serious is pneumococcal disease in the U.S.?
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%.
Vaccine Products Back to top
Which pneumococcal vaccines are licensed for use in the United States?
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 PVC13 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.
What are the differences between polysaccharide and conjugate vaccines?
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.
What are the main differences between pneumococcal polysaccharide vaccine (PPSV23) and pneumococcal conjugate vaccines (PCV13, PCV15, PCV20)?
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.
How effective are pneumococcal conjugate vaccines at preventing pneumococcal carriage or disease?
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.
How effective is pneumococcal polysaccharide vaccine at preventing pneumococcal carriage or disease?
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.
What are the recommendations for pneumococcal vaccination of children and adults?
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.
What are the different serotypes of S. pneumoniae targeted by different pneumococcal vaccines?
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
Why are PCV vaccines recommended to be given first when a patient is getting both a PCV and PPSV23 vaccines? Wouldn't PPSV23 protect them against additional strains of the pneumococcal bacteria?
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.
Recommendations for Children Back to top
When were the first conjugate vaccines licensed for children?
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.
What are the current recommendations for routine vaccination of children with PCV13?
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.
Which underlying medical conditions indicate that a child age 6 through 18 years should receive PCV13?
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.
Which children are recommended to receive pneumococcal polysaccharide vaccine (PPSV23)?
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 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
Could you briefly summarize the recommendations for PPSV23 vaccination of children?
All children 2-18 years who are at highest risk for serious pneumococcal infection (see categories 9 through 16 in previous 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.
A healthy child received only one dose of PCV13 at age 10 months. She is now 6 years old. Our state requires one dose of PCV13 after the first birthday for school attendance. Her physician says because she is older than 59 months, she does not need another dose of PCV13. What should we do in this situation?
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.
ACIP recommends pneumococcal vaccination for adult cigarette smokers age 19 through 64 years. Should we also vaccinate 16-year-olds who smoke?
No. Currently no data exist to indicate that people younger than 19 who smoke are at increased risk of pneumococcal disease.
A 2-month-old was mistakenly given PPSV23 instead of PCV13. What should be done?
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.
There is a debate within my clinical department about not allowing influenza vaccine to be given with DTaP and PCV13. Are there data that state these should not be given concomitantly?
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. See www.cdc.gov/vaccinesafety/concerns/febrile-seizures.html for more information.
A 3-year-old child who was fully vaccinated on-time with PCV13 has a diagnosis of selective IgA deficiency and was sent by her physician to the health department to receive a dose of PPSV23. Does her illness fall under the criteria for administering PPSV23?
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.
Recommendations for Adults Back to top
What are the major changes in the ACIP recommendations for pneumococcal vaccination of adults published by CDC on January 28, 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.
What are the categories of medical conditions and other risk factors among adults for which pneumococcal vaccination is recommended? And what is the recommendation?
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.
My patient just turned 65 and has never had a pneumococcal vaccine. What are my options now?
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
My patient just turned 65 and had a dose of PPSV23 at age 50 due to alcoholism. What is due now?
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
My patient is 35 and is scheduled for a splenectomy. He has never had a pneumococcal vaccine. What do I do?
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.
My patient is currently age 57 and has a history of splenectomy 8 years ago. He has received PCV13 and one dose of PPSV23 in the past. What does he need now?
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.
My patient received PCV13 a year ago and is now due for PPSV23, but my clinic only has PCV20; we do not have PPSV23 in stock. What do I do?
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.
My patient is now 70 years old and had PCV13 followed by PPSV23 after he turned 65. What is due now?
Nothing. People who have had PCV13 and PPSV23 after the 65th birthday are not currently recommended to receive any additional doses of pneumococcal vaccine.
My patient is 80 and had a dose of PPSV23 at age 65. What is due now?
There are two options:
One dose of PCV20, or
One dose of PCV15
No additional doses of PPSV23 are recommended for a person who received a dose of PPSV23 after the 65th birthday, regardless of the interval since vaccination.
Is there any role for PCV13 in adults?
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.
Is PPSV23 alone currently routinely recommended for any adults?
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, even if they were only recommended to receive a single dose of PPSV23 alone in the past. Recipients of PPSV23 should 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.
I have a patient who takes adalimumab (Humira) for rheumatoid arthritis. Does a person who takes adalimumab meet the definition of immunosuppression for the purposes of pneumococcal vaccination of adults 19-64 years?
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.
If a patient has a history of cerebrospinal fluid (CSF) leak but no current leak, is this a risk factor and a reason to administer PCV15 or PCV20 to an adult?
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.
Does an adult younger than age 65 years with beta thalassemia minor meet the criteria for a recommendation for vaccination with PCV15 or PCV20?
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.
For adults age 65 years and older without high-risk conditions who have already received PCV13, should they now get PCV15 or PCV20?
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.
For adults who have already received PCV13 or who will receive PCV15, and a PPSV23 vaccination is recommended 1 year later, what is the definition of a year? Does it need to be exactly one year? We previously provided PCV13 to some individuals during flu season and told them to get the PPSV23 next year when they get their flu shot. What if they received their flu shot in November last year, but return for their flu shot in October this year?
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)."
If a provider for adult patients does not stock PCV15 but stocks PPSV23, should that provider refer patients to another provider to ensure they receive the PCV15 dose first? Or should the provider not miss an opportunity to give the PPSV23 and refer patients elsewhere for PCV15 in a year?
The Advisory Committee on Immunization Practices (ACIP) recommends that pneumococcal vaccine-nave adults who will be receiving both PCV15 and PPSV23 should receive PCV15 first, followed by PPSV23 one year later. If the provider is unwilling to stock PCV15, then patients recommended for PCV15 should be referred elsewhere. They may get PCV15 and return a year later for PPSV23 or they may get a dose of PCV20, which does not require any future doses.
We have a 19-year-old patient with a history of vasculitis, nephritis, and asthma. She is on azathioprine (Imuran) and is immunosuppressed. Her rheumatologist recommends she receive pneumococcal conjugate vaccine and meningococcal B vaccine. How often should these vaccines be given?
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.
We have a 45-year-old patient taking Mesalamine for ulcerative colitis. Should pneumococcal vaccination be recommended for this patient?
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.
Can we administer any of the pneumococcal vaccines to patients with multiple sclerosis?
Multiple sclerosis is not a contraindication to any vaccine, including pneumococcal vaccines.
Adults who have no spleen need a pneumococcal conjugate vaccination (PCV) and a MenACWY meningococcal vaccine. In children, one brand of MenACWY (Menactra) is not supposed to be administered at the same time as PCV. Does this apply to adults, as well?
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.
Is a patient age 60 years who recently had a prostatectomy with lymph node dissection for prostate cancer a candidate for pneumococcal vaccination? The patient is believed to be cancer-free and is on no chemotherapy.
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.
I have patients who are in their 70s and 80s and remember getting a pneumococcal vaccine a few years ago. Should we assume that this was PPSV23? Should I assume that it was given before the 65th birthday?
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.
Please explain why people with asthma and people who smoke cigarettes are recommended to be vaccinated against pneumococcal disease?
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.
Since pneumococcal vaccination is recommended for all adults who smoke cigarettes, should adults who use smokeless tobacco products (e.g., chewing tobacco) or who vape nicotine be vaccinated too?
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.
Is pneumococcal vaccination indicated for former smokers younger than age 65?
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).
Does a patient younger than age 65 years who smokes marijuana regularly, but doesn't smoke cigarettes, need to receive pneumococcal vaccination?
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.
How has the ACIP recommendation for vaccination of smokers 19 through 64 changed in 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 should now receive a dose of either PCV20 or PCV15 at least one year after their dose of PPSV23.
ACIP now recommends either PCV20 alone or PCV15 followed by PPSV23 one year later for adults with asthma. Should I vaccinate people with mild, intermittent asthma or exercise-induced asthma?
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.
Would you include obstructive sleep apnea as chronic pulmonary disease which would require pneumococcal vaccination for adults under the age of 65?
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.
Should people who are HIV positive receive pneumococcal vaccines?
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.
Is systemic lupus erythematosus (SLE, lupus) a risk-based indication for pneumococcal vaccines?
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.
How often should diabetic patients receive PPSV23?
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 should receive 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.
Pneumococcal vaccination is recommended for people with diabetes. Does this include gestational diabetes?
No.
How often should adult dialysis patients receive pneumococcal vaccines?
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.
Adults who have had PCV13 Back to top
Now that we have PCV20 and PCV15, is any adult still recommended to receive multiple doses of PPSV23?
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.
We have a patient who has had PCV13 as an adult and is due for PPSV23. Our pharmacy does not have PPSV23 in stock but does have PCV20. Should we send the patient elsewhere?
That is not necessary. Although PPSV23 is recommended, CDC has stated that PCV20 may be used if PPSV23 is unavailable.
My 43-year-old patient who is about to undergo a splenectomy received PCV15 followed by PPSV23 eight weeks later in preparation for the procedure. When should she get her next dose of PPSV23?
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.
Which adults ages 19–64 years should receive a second dose of PPSV23 before age 65?
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
Do patients who were vaccinated with one or two doses of PPSV23 before age 65 need an additional dose of PPSV23 at age 65 or later?
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 should receive a single dose of PCV15 or PCV20. If they have already received either PCV20 or PCV15, then no additional PPSV23 doses are needed.
Should an 80-year-old patient who was given PPSV23 at age 65 years be revaccinated with PPSV23?
No. ACIP does not recommend revaccination with PPSV23 for any adult who has received a dose of PPSV23 after turning 65. The patient should, however, receive either PCV15 or PCV20 if they have not already received PCV13.
Miscellaneous Vaccine Issues Back to top
My patient has had laboratory-confirmed pneumococcal pneumonia. Does this patient still need to be vaccinated against pneumococcal disease?
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.
If influenza vaccine is recommended for healthcare workers to protect high-risk patients from getting influenza, why aren't the pneumococcal vaccines also recommended?
Influenza virus is easily spread from healthcare workers to their patients, and infection usually leads to clinical illness. Pneumococcus is probably not spread from healthcare workers to their patients as easily as is influenza, and infection with pneumococcus does not necessarily lead to clinical illness. Host factors (such as age, underlying illness) are more important in the development of invasive pneumococcal disease than nasopharyngeal colonization with the organism.
Why should we not give PCV vaccines to someone who has had a serious reaction to a diphtheria-containing vaccine in the past?
PCV vaccines are conjugated to a type of diphtheria-toxoid. If someone has a past history of anaphylaxis following diphtheria-containing vaccine, it might be due to the diphtheria toxoid, and the cause of the anaphylactic allergy should be identified before the administration of a PCV vaccine. This could be difficult since no single-antigen diphtheria toxoid is available in the U.S. Fortunately, true anaphylactic allergy to diphtheria-containing vaccine is rare.
Scheduling and Documenting Vaccines Back to top
When a patient is due for both PPSV23 and a pneumococcal conjugate vaccine, why does it matter which one I give first?
When both a pneumococcal conjugate vaccine (PCV) and PPSV23 are to be administered, PCV is always recommended to be given before PPSV23, based on studies demonstrating a better response to serotypes common to both vaccines when PCV was given first. These vaccines should not be given at the same visit. The routine interval between PCV and PPSV23 is one year; however, the minimum interval between PCV and PPSV23 of 8 weeks may be used when protection from pneumococcal serotypes unique to PPSV23 is required quickly (e.g., due to a high-risk condition such as asplenia).
Can we administer PCV15 and PPSV23 vaccines to a person 65 years of age or older at the same visit? If not, what is the recommended interval between doses?
No, PCV15 and PPSV23 vaccines should not be given at the same visit. When administering PCV15 followed by PPSV23, give PCV15 first followed by PPSV23 one year later. Providers can consider a minimum interval of 8 weeks later for people with immunocompromising conditions, CSF leaks, or cochlear implants who may benefit from more rapid protection against serotypes unique to PPSV23.
If a patient inadvertently received PPSV23 before PCV15, an interval of at least 1 year between doses is recommended and a shorter interval is not recommended.
What dosing intervals should be observed when giving PCV13 and PPSV23 to children who are recommended to receive both vaccines?
Give PCV13 followed by PPSV23 at least 8 weeks later. PCV13 and PPSV23 should not be given at the same visit. If a child has already received PPSV23, wait 8 weeks before giving PCV13.
One of our team administered PCV13 and PPSV23 at the same visit to a 5-year-old child who is immunocompromised. We know the PPSV23 was supposed to be administered at least 8 weeks later. We are looking for guidance for what to do now.
PCV vaccines and PPSV23 should not be administered at the same visit or at an interval less than 8 weeks.
In children, if PCV13 and PPSV23 are administered at the same visit, the PCV13 dose should be repeated, and should be administered no earlier than 8 weeks after doses that were administered on the same day. However, in adults, if a PCV and PPSV23 are administered at the same visit or at an interval less than 8 weeks, CDC recommends that neither dose needs to be repeated.
Our patient is a 78-year-old female who received PCV13, then received PPSV23 approximately 10 weeks later. She had not received PPSV23 previously. Is the PPSV23 dose valid, or does it need to be repeated?
Even though the interval was shorter than the recommended one year, the dose of PPSV23 should be counted and does not need to be repeated. In the future, please note the ACIP recommends that the routinely recommended interval between PCV13 or PCV15 and PPSV23 is 1 year, and the minimum interval is 8 weeks.
We have a 68-year-old patient who received PCV15, then received PPSV23 approximately 5 weeks later. She had not received PPSV23 previously. Is the PPSV23 dose valid, or does it need to be repeated?
What to do when doses of PCV15 and PPSV23 are given without the recommended minimum interval between them is not described in the ACIP pneumococcal recommendations. The CDC subject matter experts have provided the following guidance: in such a case, the dose given second does not need to be repeated. This is an exception to the usual procedure for a minimum interval violation (as described in ACIP's General Best Practices Guidelines for Immunization). The recommended interval between the dose of PCV15 and PPSV23 is one year and the recommended minimum interval between doses is 8 weeks.
We have a healthy 66-year-old patient who received a dose of PPSV23 in January then received a dose of PCV15 five months later at a different facility. Should the PCV15 dose be repeated since it was given earlier than the 1-year interval recommended by ACIP?
When PCV15 is given to an adult 65 years or older, PCV15 should be given first followed by PPSV23 one year later (an 8-week minimum interval may be considered for immunocompromised recipients).
What to do when doses of PPSV23 and PCV15 are given without the recommended minimum interval is not addressed in the ACIP recommendations. The CDC subject matter experts have advised that in such a case, the dose given second does not need to be repeated. This is an exception to the usual procedure for a minimum interval violation as described in ACIP's General Best Practices Guidelines for Immunization (see www.cdc.gov/vaccines/hcp/acip-recs/general-recs/timing.html). There is no evidence to support that there are benefits to repeating the dose of PCV15.
Our 65-year-old patient needs PCV15 or PCV20 today, but we only stock PPSV23. Should we give him PPSV23 today and tell him to return in a year for PCV15?
In this case, refer to where the patient may receive either PCV20 alone or PCV15 with plans to receive PPSV23 one year later. ACIP recommends that pneumococcal conjugate vaccine be administered before PPSV23 for optimal immune response to vaccination. If there is a challenge in finding another provider who has PCV15 or PCV20 then administer PPSV23; it is better to give PPSV23 then nothing at all.
If patients 19 through 64 years who are in a recommended risk group for pneumococcal vaccination aren't sure if they have previously been vaccinated with a pneumococcal vaccine, should healthcare providers vaccinate them?
Yes. If patients have an uncertain vaccination history and their records are not readily obtainable, you should administer the recommended doses: PCV20 alone or PCV15 followed by PPSV23 one year later. Extra doses will not cause harm to the patient. Per the CDC General Best Practices for Immunization Guidelines, self-reported doses of influenza and PPSV23 are acceptable. Therefore, if a patient recalls receiving PPSV23, it is acceptable to provide one dose of PCV20 or one dose of PCV15.
We gave PPSV23 to a 66-year-old patient who is newly diagnosed with a medical condition that places him at increased risk for pneumococcal disease and its complications. Should we give him a second dose in 5 years because of his underlying medical condition?
No. However, this person should receive PCV15 or PCV20 one year after PPSV23 if they have no history or an unknown history of receiving a pneumococcal conjugate vaccine in the past.
When should I vaccinate children or adults who are planning to have either a cochlear implant or elective splenectomy?
It is preferable that the person planning to have the procedure be protected from pneumococcus at the time of the surgery; if possible, administer the appropriate vaccine prior to the splenectomy or cochlear implant. If the procedure is done on an emergency basis, vaccinate as soon as possible after surgery. Adults who have not previously received any pneumococcal vaccine should receive either PCV20 alone or PCV15 followed by PPSV23 at least 8 weeks later.
PCV15 and PCV20 are not licensed or recommended for children younger than 19 years at this time. Children 2 through 71 months of age who are up to date on PCV13 should continue to receive PPSV23 vaccine according to the schedule. They are recommended to receive a second dose of PPSV23 5 years after the first PPSV23 and at least 1 year after their most recent dose of PCV13.
Do any of the bacterial vaccines that are recommended for people with functional or anatomic asplenia need to be given before splenectomy? Do the doses count if they are given during the 2 weeks prior to surgery?
Pneumococcal conjugate vaccines, Haemophilus influenzae type b vaccine, meningococcal ACWY conjugate vaccine, and meningococcal B vaccine should be given at least 14 days before splenectomy, if possible. Doses given during the 2 weeks (14 days) before surgery can be counted as valid. If the doses cannot be given prior to the splenectomy, they should be given as soon as the patient's condition has stabilized after surgery. Pneumococcal polysaccharide vaccine should be administered 8 weeks after the dose of PCV13 for people 2-18 years of age or after PCV15 for people 19 years or older. People age 19 or older who receive PCV20 do not need PPSV23.
How should we administer both pneumococcal vaccines (PCV13 and PPSV23) to our high-risk pediatric patients?
All children with risk factors for pneumococcal disease or its complications should be vaccinated with PPSV23 beginning at age 2 years. If they are age-eligible and are due for a dose of PCV13, give PCV13 first and then wait 8 weeks before giving PPSV23. For more information on vaccination of high-risk pediatric patients, see pages 26–27 of the ACIP statement at www.cdc.gov/mmwr/pdf/rr/rr5911.pdf.
Some physicians in our area order PPSV23 every 5 years for their patients. Is this correct?
No. Only certain high-risk people who were vaccinated with PCV13 and PPSV23 when younger than age 65 years will need a second dose of PPSV23 5 years later. At age 65 years or older, all adults with no or unknown history of PCV vaccination are now recommended to have either a single dose of PCV20 alone or a dose of PCV15 followed by a dose of PPSV23 one year later.
For people 65 and older who have had a prior PCV13 vaccine, then CDC recommends a single dose of PPSV23 at least one year after PCV13 (and at least 5 years after any prior PPSV23 dose given before age 65 years). If PPSV23 is unavailable at the time vaccination is due, but PCV20 is available, PCV20 may be administered instead of PPSV23.
Can we vaccinate a 2-year-old boy with functional or anatomic asplenia against meningococcal disease if he has not completed a series of PCV13?
Yes, depending on the brand you use. If you are using Menveo (MenACWY-CRM, GSK) or MenQuadfi (MenACWY-TT, Sanofi Pasteur), they may be administered at the same time as PCV13 or at any interval before or after receipt of PCV13. If you are going to give him Menactra (MenACWY-D, Sanofi Pasteur), you need to wait at least 4 weeks after he completes the PCV13 series before giving him the Menactra to avoid the possibility of interference with the immune response to PCV13.
We have a 10-year-old getting renal dialysis. There is no history of previous PCV13 administration. The nephrologist will be starting her on a monoclonal antibody that interferes with C5 complement. If we administer meningococcal conjugate (MenACWY) and a PPSV23 now, and then give her a PCV13 in 8 weeks, will the PCV13 interfere with the efficacy of the PPSV23 or the MenACWY?
No, but the PPSV23 will render the PCV13 dose less immunogenic. Recommendations to separate MenACWY and PCV13 only apply to people with functional or anatomic asplenia or HIV (see next question). In this scenario, the best schedule is to give MenACWY (any brand) simultaneously with PCV13, and then PPSV23 in eight weeks. ACIP recommends giving PCV13 before PPSV23 in order to maximize the immune response from PCV13. PPSV23 may blunt the immune response to PCV13 if PCV13 is given after PPSV23, although in children there is a smaller effect than in adults. A 10-year-old with persistent complement component deficiency should also receive a 2 or 3 dose series (depending on brand) of meningococcal B vaccine.
Can I give other vaccines at the same time I give either PCV13, PCV15, PCV20 or PPSV23 to a patient?
Yes, with several exceptions. These are all inactivated vaccines, which means you can give all other recommended vaccines at the same visit (using separate syringes) or at any later time with no waiting period following the vaccination. Here are the exceptions:
1. You cannot give both PCV and PPSV23 vaccines at the same time.
2. If the person has functional or anatomic asplenia or HIV infection, observe these rules:
  If using Menveo (MenACWY-CRM) or MenQuadfi (MenACWY-TT) you may give PCV at the same visit or at any interval before or after each other.
  If using Menactra (MenACWY-D) vaccine, you should give PCV first and wait 4 weeks after the final dose of PCV before giving Menactra.
The pneumococcal conjugate vaccine (PCV20) package insert says that in adults, antibody responses to Prevnar 13 (Pfizer) were diminished when given with inactivated influenza vaccine. Does this mean we should not give PCV20 and influenza vaccine at the same visit?
No. The available data have been interpreted that any changes in antibody response to either vaccine's components were clinically insignificant. If PCV20 and influenza vaccine are both indicated and recommended they should be administered at the same visit.
Administering Vaccines Back to top
A dose of pneumococcal conjugate vaccine was administered into my patient's dialysis port. Does this dose count?
No. There are no data on the effectiveness of pneumococcal conjugate vaccine given by the intravenous route. The patient has renal disease, so it is important to ensure that the dose they receive is effective. CDC recommends repeating the dose.
What route and needle length are recommended for administration of PPSV23 or PCV vaccines?
PPSV23 may be administered by intramuscular (IM) or subcutaneous (subcut) routes. PCV are administered IM. Immunize.org has produced a simple handout that summarizes the dose, route, site, and needle length for administration of all recommended vaccines to adults and children: www.immunize.org/catg.d/p3085.pdf.
Storage and Handling  
How should pneumococcal vaccines be stored?
PCV and PPSV23 all should be refrigerated at temperatures between 2°C (36°F) and 8°C (46°F). Do not freeze vaccines. Vaccine exposed to freezing temperature should not be administered. For details of vaccine storage and handling, see the CDC Vaccine Storage and Handling Toolkit: www.cdc.gov/vaccines/hcp/admin/storage/toolkit/index.html.
Back to top
This page was updated on March 22, 2022.
This page was reviewed on March 22, 2022.
 
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