As an additional service to IZ Express readers, we periodically publish special editions such as this one, providing you with new and updated Ask the Experts questions and answers from Immunize.org’s experts. This issue includes 15 Q&As about pneumococcal vaccination of adults based on the new ACIP recommendations published January 28, 2022.
To find the full set of Immunize.org’s Ask the Experts pneumococcal vaccination Q&As, visit www.immunize.org/askexperts/experts_pneumococcal_vaccines.asp.
You can find all of these questions and answers, plus more than a thousand others about vaccines and vaccine administration, on our "Ask the Experts" gateway page at www.immunize.org/askexperts.
Immunize.org's team of experts includes Kelly L. Moore, MD, MPH (team lead), Carolyn B. Bridges, MD, FACP, and Iyabode Beysolow, MD, MPH.
COVID-19 Vaccination Questions
Q. What are the major changes in the ACIP recommendations for pneumococcal vaccination of adults published by CDC on January 28, 2022?
A: 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.
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Q. What are the categories of medical conditions and other risk factors among adults for which pneumococcal vaccination is recommended? And what is the recommendation?
A: 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):
- cigarette smoking (does not include people who vape)
- alcoholism
- chronic liver disease, including cirrhosis
- chronic heart disease (e.g., congestive heart failure, cardiomyopathies), excluding hypertension
- chronic lung disease (including COPD and emphysema, and asthma)
- diabetes mellitus
- candidate for or recipient of cochlear implant
- cerebrospinal fluid (CSF) leak
- functional or anatomic asplenia (e.g., splenectomy or congenital asplenia)
- sickle cell disease and other hemoglobinopathies
- 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])
- generalized malignancy
- HIV infection
- Hodgkin disease, leukemia, lymphoma, and multiple myeloma
- immunosuppression due to treatment with medication, including long-term systemic corticosteroids, and radiation therapy
- solid organ transplantation; for bone marrow transplantation; see www.cdc.gov/vaccines/hcp/acip-recs/general-recs/immunocompetence.html
- 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.
Q. My patient just turned 65 and has never had a pneumococcal vaccine. What are my options now?
A: 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
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Q. My patient just turned 65 and had a dose of PPSV23 at age 50 due to alcoholism. What is due now?
A: 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
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Q. My patient is 35 and is scheduled for a splenectomy. He has never had a pneumococcal vaccine. What do I do?
A: 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.
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Q. 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?
A: 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 (third) 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.
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Q. 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?
A: 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.
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Q. My patient is now 70 years old and had PCV13 followed by PPSV23 after he turned 65. What is due now?
A: Nothing. People who have had PCV13 and PPSV23 after the 65th birthday are not currently recommended to receive any additional doses of pneumococcal vaccine.
Q. My patient is 80 and had a dose of PPSV23 at age 65. What is due now?
A: 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.
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Q. Is there any role for PCV13 in adults?
A: 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.
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Q. Is PPSV23 alone currently routinely recommended for any adults?
A: 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.
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Q. How often should diabetic patients receive PPSV23?
A: 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.
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Q. Now that we have PCV20 and PCV15, is any adult still recommended to receive multiple doses of PPSV23?
A: 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.
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Q. 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?
A: 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.
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Q. My patient has had laboratory-confirmed pneumococcal pneumonia. Does this patient still need to be vaccinated against pneumococcal disease?
A: 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.
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