How Often To Get Pneumococcal Vaccine

Pneumococcal Vaccines (PCV13 and PPSV23)

Disease Issues		Miscellaneous Vaccine Issues

Vaccine Recommendations (PCV13) for Children		Scheduling and Documenting Vaccines

Vaccine Recommendations (PCV13) for Adults		Administering Vaccines

Vaccine Recommendations (PPSV23) for Children and Adults		Storage and Handling

Boosters and Revaccination (PPSV23)

Disease Issues

What causes pneumococcal disease?

Pneumococcal disease is caused by Streptococcus pneumoniae, a bacterium that has more than 90 serotypes. Most serotypes cause disease, but only a few produce the majority of invasive pneumococcal disease. The 10 most common types cause 62% of invasive disease worldwide.

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.

How long does it take to show signs of pneumococcal disease after being exposed?

As noted above, many people carry the bacteria in their nose and throat without ever developing invasive disease.

What are the types of invasive pneumococcal disease?

There are two major clinical syndromes of invasive pneumococcal disease: bacteremia, and meningitis. They are both caused by infection with the same bacteria, but have different manifestations.

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, or it can occur alone. Isolated pneumococcal pneumonia is not considered invasive disease but it 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.

More than 5,000 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 70% of invasive disease in this 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. An estimated 31,000 cases and 3,590 deaths from invasive pneumococcal diseases (IPD-bacteremia and -meningitis) occurred in the United States in 2017 (see www.cdc.gov/abcs/reports-findings/survreports/spneu17.html). Young children and the elderly (younger than age two years and older than 50) have the highest incidence of serious disease. Case-fatality rates are highest for pneumococcal meningitis and bacteremia, and the highest mortality occurs among the elderly and patients who have underlying medical conditions. The overall case-fatality rate for pneumococcal bacteremia is about 20% among adults. Among elderly patients, this rate may be as high as 60%.

Vaccine Recommendations (PCV13) for Children

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When were the first conjugate vaccines licensed?

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 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.

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 www.cdc.gov/mmwr/pdf/rr/rr5911.pdf.

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 6 – 18 years old 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 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.

What are the recommendations for PCV13 vaccination of children who previously received PCV7?

IAC has produced a document that describes pneumococcal vaccination recommendations based on the child's current age and prior vaccination history. The document is available at www.immunize.org/catg.d/p2016.pdf.

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 at this age should not be considered to be 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.

Vaccine Recommendations (PCV13) for Adults

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What changed in November 2019 regarding ACIP pneumococcal conjugate vaccine (PCV13, Prevnar, Pfizer) recommendations for adults age 65 years and older?

According to the updated Advisory Committee on Immunization Practices (ACIP) recommendations published November 22, 2019, PCV13 vaccination is no longer routinely recommended for all adults 65 years and older. Instead, shared clinical decision-making for PCV13 use is recommended for adults age 65 years and older who do not have an immunocompromising condition, cerebrospinal fluid (CSF) leak, or cochlear implant. PCV13 continues to be recommended for all adults with immunocompromising conditions, cerebrospinal fluid (CSF) leak, or cochlear implant.

Immunocompromising conditions include chronic renal failure, nephrotic syndrome, congenital or acquired immunodeficiency, iatrogenic immunosuppression, generalized malignancy, human immunodeficiency virus, Hodgkin disease, leukemia, lymphoma, multiple myeloma, solid organ transplants, congenital or acquired asplenia, sickle cell disease, or other hemoglobinopathies.

The 2019 PCV13 recommendations update ACIP's 2014 statement which recommended routine use of pneumococcal conjugate vaccine (PCV13) in series with pneumococcal polysaccharide vaccine (PPSV23) for all adults 65 years and older. The incidence of PCV13-type disease has been reduced to historically low levels among adults age 65 years and older through indirect effects from pediatric PCV13 use. Because of this changing epidemiology, ACIP updated its recommendations on PCV13 vaccine scheduling in older adults and incorporated the concept of shared clinical decision-making, as summarized in the question and answer below. Pneumococcal polysaccharide vaccine (PPSV23, Pneumovax, Merck) continues to be recommended for all adults age 65 years and older.

For more information, the most recent ACIP pneumococcal vaccine recommendations can be accessed at: www.cdc.gov/mmwr/volumes/68/wr/pdfs/mm6846a5-H.pdf.

What is CDC's guidance for shared clinical decision-making for PCV13 vaccination of adults age 65 years and older?

When patients and vaccine providers engage in shared clinical decision-making for PCV13 use to determine whether PCV13 is right for the specific individual age 65 years and older, considerations include the individual patient's risk for exposure to PCV13 serotypes and the risk for pneumococcal disease for that person as a result of underlying medical conditions. These considerations are detailed below.

•		PCV13 is a safe and effective vaccine for older adults. The risk for PCV13-type disease among adults age 65 years and older is much lower than it was before the pediatric program was implemented. The remaining risk is a function of each individual patient's risk for exposure to PCV13 serotypes and the influence of underlying medical conditions on the patient's risk for developing pneumococcal disease if exposure occurs.
•		The following adults age 65 years and older are potentially at increased risk for exposure to PCV13 serotypes and might attain higher than average benefit from PCV13 vaccination, and providers/practices caring for many patients in these groups may consider regularly offering PCV13 to their patients age 65 years and older who have not previously received PCV13:
		o Persons residing in nursing homes or other long-term care facilities
		o Persons residing in settings with low pediatric PCV13 uptake
		o Persons traveling to settings with no pediatric PCV13 program
•		Incidence of PCV13-type invasive pneumococcal disease and pneumonia increases with increasing age and is higher among persons with chronic heart, lung, or liver disease, diabetes, or alcoholism, and those who smoke cigarettes or who have more than one chronic medical condition. Although indirect effects from pediatric PCV13 use were documented for these groups of adults and were comparable to those observed among healthy adults, the residual PCV13-type disease burden remains higher in these groups. Providers and practices caring for patients with these medical conditions may consider offering PCV13 to such patients who are age 65 years and older and who have not previously received PCV13.

If PCV13 is given based on shared clinical decision-making, when should PCV13 be given?

If PCV13 is recommended for an adult age 65 years or older based on shared clinical decision-making, PCV13 should be administered first followed by PPSV23 one year later.

If PCV13 is given to adults of any age with immunocompromising conditions, CSF leaks, or cochlear implants, then PCV13 should be given first followed by PPSV23 at least 8 weeks later.

If PPSV23 has already been given, the PCV13 should be given at least 1 year later.

PCV13 and PPSV23 should not be given at the same time.

Did the recommendation change in November 2019 for PPSV23 vaccination of adults age 65 years and older?

No. ACIP continues to recommend that all adults age 65 years and older routinely receive 1 dose of PPSV23. PPSV23 contains 12 serotypes in common with PCV13 and an additional 11 serotypes for which there are no indirect effects from PCV13 use in children. The additional 11 serotypes account for 32%–37% of invasive pneumococcal disease among adults age 65 years and older. Adults age 65 years and older who received one or more doses of PPSV23 before age 65 years should receive one additional dose of PPSV23 at age 65 years or older, at least 5 years after the previous PPSV23 dose.

Which high-risk adults are recommended to receive a dose of PCV13?

Pneumococcal conjugate vaccine (PCV13, Prevnar 13, Pfizer) is recommended for all adults without a prior PCV13 vaccination who have a high-risk condition, including immunocompromising conditions, cerebrospinal fluid (CSF) leak, and cochlear implant.

PCV13 can be given to adults age 65 years and older without these high-risk conditions based on shared clinical decision-making. Considerations for PCV13 vaccination of adults age 65 years and older without these high-risk conditions include any potential increased risk for exposure to PCV13 serotypes, such as residing in a nursing home or other long-term care facility, residing in settings with low PCV13 vaccination rates among children, or traveling to areas with no PCV13 vaccination coverage, and their risk of getting pneumococcal disease as a result of underlying medical conditions, such as chronic heart, lung or renal disease, diabetes, alcoholism, or smoking cigarettes.

For complete information on CDC's recommendations for the use of pneumococcal vaccines, go to www.immunize.org/acip/#pneu.

How effective is PCV13 vaccine in adults 65 years and older?

The CAPiTA PCV13 vaccine trial demonstrated 45.6% (95% confidence interval [CI] = 21.8%–62.5%) efficacy of PCV13 against vaccine-type pneumococcal pneumonia, 45.0% (CI = 14.2%–65.3%) efficacy against vaccine-type nonbacteremic pneumococcal pneumonia, and 75.0% (CI = 41.4%–90.8%) efficacy against vaccine-type invasive pneumococcal disease (IPD) among adults age 65 years and older. PCV13 is licensed for use among adults 50 years of age and older.

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 PCV13 vaccination?

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. Consequently, 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 PCV13 followed by PPSV23 at least 8 weeks later.

Please explain why pneumococcal polysaccharide vaccine is recommended for smokers or people with diabetes younger than age 65 but pneumococcal conjugate vaccine is not recommended for these groups.

The level of risk for pneumococcal disease in smokers and people with diabetes is not as high as in immunocompromised persons, or persons with asplenia, HIV infection, hematologic cancer, or cochlear implant. Because of the lower risk, ACIP recommended that smokers and people with diabetes receive only pneumococcal polysaccharide vaccine (PPSV, Pneumovax 23; Merck) once before age 65 years, and again at age 65 years or older. At this age, pneumococcal disease rates increase regardless of health status.

One dose of the pneumococcal conjugate vaccine (PCV13; Pfizer) is recommended for immunocompromised persons, and persons with asplenia, HIV infection, hematologic cancer, or cochlear implant.

More information on vaccination of adults with PPSV23 and PCV13 is available at www.cdc.gov/mmwr/volumes/68/wr/pdfs/mm6846a5-H.pdf and www.cdc.gov/mmwr/pdf/wk/mm6140.pdf.

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 PCV13 and PPSV23 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 PCV13?

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

Why is PCV13 recommended to be given first when a patient is getting both PCV13 and PPSV23 vaccines? Wouldn't PPSV23 protect them against ten additional strains of the pneumococcal bacteria?

PCV13 is recommended to be given first because of the immune response to the vaccine when given in this sequence. 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.

For adults age 65 years and older without high-risk conditions who receive both PCV13 and PPSV23, a 1-year interval is recommended between PCV13 and PPSV23 vaccines. What is the definition of a year? Does it need to be exactly one year? We have provided PCV13 to some individuals during flu season this year and told them to get the PPSV23 next year when they get their flu shot. What if they received their flu shot in November this year, but return for their flu shot in October next year?

What you describe is an excellent strategy for administration of PCV13 and PPSV23 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 is not a medical problem. However, it could be a problem for reimbursement since Medicare will only pay for both vaccines 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 does not stock pneumococcal conjugate vaccine (PCV13, Prevnar 13, Pfizer) but stocks pneumococcal polysaccharide vaccine (PPSV23, Pneumovax 23, Merck), should that provider refer patients to another provider to ensure they receive the PCV13 dose first? Or should the provider not miss an opportunity to give the PPSV23 and refer patients elsewhere for PCV13 in a year?

The Advisory Committee on Immunization Practices (ACIP) recommends that pneumococcal vaccine-na�ve people who will be receiving both PCV13 and PPSV23 should receive PCV13 first, followed by PPSV23 8 weeks later if they have a high-risk condition or one year later if they are 65 years and older without a high risk conditions. If the provider is unwilling to stock PCV13, then patients recommended for PCV13 should be referred elsewhere to get PCV13 first. A solution to this problem is to stock PCV13 and PPSV23.

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? Will she require a series of PCV13 doses or just a booster?

For people with immunosuppression, ACIP recommends 1 dose of PCV13 followed by a dose of PPSV23 at least 8 weeks later (see www.cdc.gov/mmwr/pdf/wk/mm6434.pdf, pages 944–7). Meningococcal serogroup B vaccine (MenB) is not specifically recommended for immunosuppressed people. However, people age 16 through 23 years who are not at increased risk may receive routine MenB vaccination of either a 2-dose series of Bexsero (GSK) 4 weeks apart, or a 2-dose series of Trumenba (Pfizer) 6 months apart.

We have a 45-year-old patient taking Mesalamine for ulcerative colitis. Should he receive PCV13 and/or PPSV23?

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 either the pneumococcal polysaccharide (PPSV23) or the pneumococcal conjugate vaccine (PCV13) to patients with multiple sclerosis?

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

Adults who are asplenic need PCV13 and MenACWY. Does the recommendation to separate PCV13 and MenACWY-D (Menactra) apply to adults as well as children?

Studies that showed possible interference when PCV7 and Menactra were given simultaneously were done in children. This was then extrapolated to use of PCV13 and MenACWY-D in children. This interference was not noted with MenACWY-CRM (Menveo).

At this time, there are no data to support a similar recommendation for adults. However, to be prudent, if MenACWY-D is being used, you should space it 4 weeks after PCV13 if possible. With both asplenic children and asplenic adults, if less than four weeks separate MenACWY-D and PCV13 (in either order), the dose of PCV13 should be repeated four weeks after whichever vaccine was administered second. MenACWY-CRM can be administered at any time before, simultaneous with, or after PCV13. Children and adults with functional or anatomic asplenia should be given PPSV23 at least 8 weeks after PCV13.

Vaccine Recommendations (PPSV23) for Children and Adults

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When were the first vaccines licensed for vaccination against pneumococcal disease?

The first pneumococcal vaccine, licensed in 1977, was a polysaccharide vaccine. It contained purified capsular polysaccharide antigen from 14 different types of pneumococcal bacteria. In 1983, a 23-valent polysaccharide was licensed (PPSV23; Pneumovax, Merck). It replaced the 14-valent vaccine.

Who is recommended to receive pneumococcal polysaccharide vaccine (PPSV23)?

PPSV23 (Pneumovax, Merck) is recommended for anyone who meets any of the criteria below:

�	Age 65 years and older
�	Age 2 through 64 years with any of the following conditions
	1.	cigarette smokers age 19 years and older
	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 for adults age 19 years and older, 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 may also consider recommending PPSV23 for Alaska Natives and American Indians ages 50 through 64 years who are living in areas in which the risk of invasive pneumococcal disease is increased.

Could you briefly summarize the revaccination recommendations for PPSV23?

Children and adults younger than age 65 who are at highest risk for serious pneumococcal infection (see categories 9 through 17 in previous answer) should get 2 doses of PPSV23 five years apart, with a third dose after they turn age 65 (if at least 5 years have passed since the last dose).

Patients with risk factors 1 through 8 above should get one dose of PPSV23 before age 65 and then a second dose after they turn 65 years (if at least 5 years have passed since the last dose).

Patients with no risk factors should get 1 dose at age 65. Thus, depending on risk and age at vaccination, an adult may have received 1, 2, or 3 doses of PPSV23.

How effective is PPSV23 vaccine for adults 65 years and older?

PPSV23 vaccine is 60%–80% effective against invasive pneumococcal disease when it is given to immunocompetent people age 65 years and older or people with chronic illnesses. The vaccine is less effective in immunocompromised people. The effectiveness of this vaccine in preventing noninvasive pneumococcal pneumonia among adults age 65 years and older have been inconsistent.

Is a patient younger than age 65 years who recently had a prostatectomy with lymph node dissection for prostate cancer a candidate for PPSV23? 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 PPSV23.

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 PPSV23 and PCV13 were both routinely recommended for all adults 65 years of age and older from 2014–2019, it cannot be assumed which pneumococcal vaccine they received. Ideally, providers and patients should work to verify which vaccines were received, including by querying the jurisdiction's immunization information system where the patient was likely vaccinated.

If vaccination records cannot be obtained, then the patient should be vaccinated.

All patients should receive PPSV23 at age 65 years or older. If a patient has a high-risk indication for PCV13 or PCV13 is recommended based on shared clinical decision-making, then PCV13 should be given first followed by PPSV23.

*Note: Per the CDC General Best Practices for Immunization Guidelines, self-reported doses of influenza and PPSV23 are acceptable. All other vaccines must be documented with a written, dated record.

Which children should receive PPSV23 vaccine (in addition to PCV13)? At what age should they receive it?

PPSV23 is recommended for children with an immunocompromising condition, or functional or anatomic asplenia, and also for immunocompetent children with chronic heart disease, chronic lung disease, diabetes mellitus, CSF leak, or cochlear implant. Administer 1 dose of PPSV23 to children age 2 years and older at least 8 weeks after the child has received the final dose of PCV13. Children with an immunocompromising condition, or functional or anatomic asplenia should receive a second dose of PPSV23 5 years after the first PPSV23.

Is PPSV23 contraindicated in pregnancy? Our patient has asthma and is pregnant.

No. PPSV23 is recommended in pregnancy if some other risk factor is present (for example, on the basis of medical, occupational, lifestyle, or other indication). For more information refer to the adult schedule available at www.cdc.gov/vaccines/schedules/hcp/adult.html.

Can you please explain when and why the recommendations for vaccination were changed for people with asthma and for cigarette smokers?

In 2008, the Advisory Committee on Immunization Practices (ACIP) reviewed information that suggests that asthma is an independent risk factor for pneumococcal disease among adults. ACIP also reviewed information that demonstrates an increased risk of pneumococcal disease among smokers. Consequently, ACIP recommends to include both asthma and cigarette smoking as indications for PPSV23 vaccination among adults age 19 through 64 years.

Since PPSV23 is recommended for all adults who smoke, should adults who use smokeless tobacco products (e.g., chewing tobacco) be vaccinated too?

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

Since PPSV23 is recommended for all adults who smoke, should adults who vape nicotine, but do not smoke cigarettes, be vaccinated too?

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

Currently, ACIP recommends PPSV23 for 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 and smoke are at increased risk of pneumococcal disease.

Is PPSV23 indicated for former smokers?

PPSV23 is currently recommended for people age 19 through 64 years who actively smoke cigarettes (see www.cdc.gov/mmwr/pdf/wk/mm5934.pdf). However, chronic lung disease is an indication for PPSV23, which could be applicable for former smokers.

Does a patient younger than age 65 years who smokes marijuana on a daily basis, but doesn't smoke cigarettes, need to receive pneumococcal polysaccharide (PPSV) vaccine?

No. ACIP does not identify people who smoke marijuana but not cigarettes as being at increased risk for pneumococcal disease or as being in a risk group for PPSV vaccination.

Is PCV13 recommended for adults age 19 through 64 years who smoke?

No. PCV13 is only recommended for adults age 19 through 64 years at increased risk of invasive pneumococcal disease because of an immunocompromising condition, asplenia, CSF leak or cochlear implant.

ACIP recommends vaccinating adults with asthma with PPSV23. Should I give PPSV23 to people with mild, intermittent asthma or exercise-induced asthma? Why isn't PPSV23 recommended for children with asthma?

PPSV23 (but not PCV13) 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 19 years, so PPSV23 is not currently recommended for people younger than 19 years with asthma. For more information, go to www.cdc.gov/mmwr/pdf/wk/mm5934.pdf.

Would you include obstructive sleep apnea as chronic pulmonary disease which would require PPSV23 vaccination once for adults under the age of 65?

Obstructive sleep apnea alone is not an indication for vaccination with PPSV23 for persons 2 through 64 years of age. 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. A table listing risk conditions and pneumococcal vaccine recommendations can be found at www.immunize.org/catg.d/p2019.pdf.

Should people who are HIV positive receive pneumococcal vaccines?

Yes. People with HIV infection are at high risk of pneumococcal disease. They should receive both PCV13 and PPSV23 vaccines as soon as possible after diagnosis. They should first be given PCV13, followed by PPSV23 at least 8 weeks later. If they are younger than age 65 years, they will need a second dose of PPSV23 at least 5 years after their initial PPSV23 dose and a third PPSV23 dose once they become age 65 years. If they are age 65 years or older when first diagnosed, they will need only one dose.

Is systemic lupus erythematosus (SLE, lupus) a risk-based indication for pneumococcal vaccines?

Lupus per se is not an indication for either pneumococcal vaccine. However, immunosuppressive medication that may be used to treat lupus could create an indication for administering both pneumococcal vaccines. Also, if the patient has certain complications of lupus (such as nephrotic syndrome), the person would be a candidate for pneumococcal vaccines. Both immunosuppression and nephrotic syndrome are indications for administering both PCV13 AND PPSV23. Administer PCV13 first, then PPSV23 8 weeks later. A handy document that summarizes indications for both pneumococcal vaccines is available at www.immunize.org/catg.d/p2019.pdf.

A child with selective IgA deficiency 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?

Selective IgA deficiency is a B-cell immunodeficiency, so PPSV23 is indicated if the child is age 2 years or older.

How often should diabetic patients receive PPSV23?

People with either type 1 or type 2 diabetes who are ages 2 through 64 years who have not already received a dose of PPSV23 should receive their first dose now. At age 65 years they should receive a one-time revaccination if 5 years have elapsed since the previous dose. Diabetes is not an indication for PCV13, however persons 65 years and older may be considered for PCV13 vaccination based on shared clinical decision-making between the provider and patient.

PPSV23 is recommended for people with diabetes. Does this include gestational diabetes?

No.

How often should adult dialysis patients receive pneumococcal polysaccharide vaccine?

Adult dialysis patients age who have not previously received PCV13 or PPSV23 should receive a dose of PCV13 first, followed by a dose of PPSV23 at least 8 weeks later. A second dose of PPSV23 should be given 5 years after the first dose of PPSV23. Once they become age 65, they will need another PPSV23 dose. If they were age 65 years or older when first vaccinated, only one dose of PPSV23 is recommended.

Adults age 19 years and older with immunocompromising conditions (including chronic renal failure), functional or anatomic asplenia, CSF leak, or cochlear implants, who previously have received 1 or more doses of PPSV23 should be given a PCV13 dose at least 1 year after the last PPSV23 dose was received.

Boosters and Revaccination (PPSV23)

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Could you briefly summarize the recommendations for PPSV23 revaccination?

Revaccination 5 years after the first dose of PPSV23 is recommended for 1) children and adults younger than age 65 years at highest risk for serious pneumococcal infection or who are likely to have a rapid decline in antibody levels (see next Q&A) and 2) adults age 65 years and older who received their first dose for any indication when they were younger than age 65 years. Adults who receive PPSV23 at or after age 65 years should receive only a single dose. A 5-year interval is recommended between PPSV23 vaccine doses.

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 have functional or anatomic asplenia (including persons with sickle cell disease or splenectomy patients); chronic renal failure (including dialysis patients) or nephrotic syndrome; are immunocompromised, including those with HIV infection, leukemia, lymphoma, Hodgkin disease, multiple myeloma, generalized malignancy; are receiving immunosuppressive therapy (including long-term systemic corticosteroids or radiation therapy); or who have received a 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. Patients who received 1 or 2 doses of PPSV23 for any indication at age 64 years or younger should receive an additional dose of PPSV23 vaccine at age 65 years or older if at least 5 years have elapsed since their previous PPSV23 dose.

Should a healthy 75-year-old patient who was given PPSV23 at age 65 years be revaccinated?

No. Adults who were first vaccinated at age 65 years or older do not require any more doses of PPSV23.

Why is there no recommendation for patients older than 65 years to get a booster dose of PPSV23 if they first received it at age 65 years or older? It seems to me that their protection against pneumococcal disease would benefit from a booster dose of PPSV23 five or ten years after the first dose.

People age 65 and older should be given a second dose of PPSV23 if they received the first dose 5 or more years previously and were younger than 65 years at the time of the first vaccination. Protection from a single dose of PPSV23 at age 65 years or older is believed to persist for 5–10 years. The benefit and safety of a second dose given after age 65 years is uncertain. Until such data are available, ACIP recommends only a single dose at age 65 years or older.

Miscellaneous Vaccine Issues

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I've heard that PPSV23 isn't very effective in older people. Should I still use it?

Yes. PPSV23 vaccine is 60%–80% effective against invasive pneumococcal disease when it is given to immunocompetent people age 65 years and older or people with chronic illnesses. The vaccine is less effective in immunocompromised people. So, although PPSV23 is not as effective as some other vaccines, it can significantly lower the risk of serious pneumococcal disease and its complications in most recipients.

My patient has had laboratory-confirmed pneumococcal pneumonia. Does he/she still need to be vaccinated with PCV13 and/or PPSV23?

Yes. There are more than 90 known serotypes of pneumococcus (13 serotypes in the conjugate vaccine and 23 serotypes in the polysaccharide vaccine). Infection with one serotype does not necessarily produce immunity to other serotypes. As a result, if the person is a candidate for vaccination, s/he 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. When you're giving influenza vaccine to your patients in the fall, don't forget to assess their need for pneumococcal vaccines as well as all other vaccines, including Tdap and zoster.

Why should we not give PCV13 vaccine to someone who has had a serious reaction to a diphtheria-containing vaccine in the past?

PCV13 vaccine is conjugated to a type of diphtheria-toxoid. So 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 PCV13 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

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Can we administer PCV13 and PPSV23 to a person 65 years of age or older at the same visit? If not, what is the recommended interval between doses?

PCV13 and PPSV23 should not be given at the same visit. When both vaccines are recommended, give PCV13 first followed by PPSV23 at least 8 weeks later for persons with asplenia, cochlear implant, CSF leak or immunocompromising condition. For all others, give PPSV23 at least one year after PCV13.

What dosing intervals should be observed when giving PCV13 and PPSV23 to patients (children and adults) who are recommended to receive both vaccines?

Give PCV13 before PPSV23 if possible. PCV13 and PPSV23 should not be given at the same visit. For children, if the child has already received PPSV23, wait 8 weeks before giving PCV13.

For adults at highest risk of pneumococcal disease (immunocompromised, asplenia, CSF leak, or cochlear implant), give PCV13 followed by PPSV23 at least 8 weeks later.

For adults age 19 through 64 years with other high-risk conditions (e.g., chronic heart, lung, or liver disease, diabetes, smoking, or alcoholism), give PPSV23 followed by an additional PPSV23 dose at age 65 years (at least 5 years after the first PPSV23 dose).

For people age 65 years and older with no prior pneumococcal vaccination who do not have a high-risk condition, but a decision is made, based on shared clinical decision-making, to give PCV13, give PCV13 followed by PPSV23 one year later.

For adults who have already received PPSV23 and for whom PCV13 is recommended, wait 12 months before giving PCV13.

Rather than giving PCV13 first and waiting 8 weeks to give PPSV23 as recommended for an immunocompromised child (2 years or older) or adult patient, we inadvertently gave both vaccines at the same visit. We are looking for guidance.

PCV13 and PPSV23 should not be administered at the same visit or at an interval less than 8 weeks. However, in adults, if PCV13 and PPSV23 are administered at the same visit or at an interval less than 8 weeks, neither dose needs to be repeated. 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.

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 two vaccines not be administered at the same visit, and the recommended minimum interval between PCV13 and PPSV23 is 8 weeks. Among persons age 65 years and older without CSF leak, asplenia, immunocompromising conditions, or cochlear implant, the interval is one year between PCV13 and PPSV23 when both vaccines are recommended.

We have a 68-year-old patient who received PCV13, 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 PCV13 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 PCV13 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 PCV13 five months later at a different facility. Should the PCV13 dose be repeated since it was given earlier than the 1-year interval recommended by ACIP?

When PCV13 is given to an adult 65 years or older based on shared clinical decision-making, PCV13 should be given first followed by PPSV23 one year later. When PPSV23 has been given first, ACIP recommends an interval of one year before giving PCV13. If PCV13 is given based on having a high-risk condition (e.g. immunocompromising condition, asplenia, CSF leak, and cochlear implant), then the minimum interval is 8 weeks between PCV13 and PPSV23.

What to do when doses of PPSV23 and PCV13 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 PCV13. Information about the recommended intervals between pneumococcal vaccines can be found at www.cdc.gov/mmwr/pdf/wk/mm6434.pdf, pages 944–7.

If patients who are in a recommended risk group for PPSV23 or PCV13 aren't sure if they have previously received these vaccines, should healthcare providers vaccinate them?

Yes. If patients do not have a documented vaccination history for these two vaccines and their records are not readily obtainable, you should administer the recommended doses. Extra doses will not cause harm to the patient. However, per the CDC General Best Practices for Immunization Guidelines, self-reported doses of influenza and PPSV23 are acceptable. All other vaccines must be documented with a written, dated record.

An 86-year-old patient came in today and stated he needed a pneumococcal vaccine booster. He reports receiving a dose of "pneumonia vaccine" when he was 77 years old. Which pneumococcal should he receive today, PCV13 or PPSV23?

People who receive PPSV23 at age 65 years or older are not recommended to receive additional doses of PPSV23. And PCV13 is given as a one-time dose when given to adults. If the person received their first pneumonia vaccine before 2014, they would have received PPSV23. Both PPSV23 and PCV13 were recommended for all persons 65 years and older during 2014–2019. If the person is unsure which pneumococcal vaccine they received and they do not have documentation, then they should receive PPSV23. The provider and patient may consider PCV13 vaccination based on shared clinical decision-making if the person does not have a high-risk indication for PCV13 (i.e. immunocompromising condition, asplenia, CSF leak or cochlear implant).

We just 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. People who are first vaccinated with PPSV23 at age 65 years or older should receive only one dose, regardless of any underlying medical condition they might have.

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 have antibody to pneumococcus at the time of the surgery; if possible, administer the appropriate vaccine prior to the splenectomy or cochlear implant. Children 2 through 71 months of age should continue to receive PCV13 vaccine according to the schedule. If the procedure is done on an emergency basis, vaccinate as soon as possible after surgery. Persons who have not previously received any pneumococcal vaccine should receive PCV13 first followed by PPSV23 at least 8 weeks later. Asplenic persons need a second dose of PPSV23 5 years after the first PPSV23.

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 vaccine (PCV13), Haemophilus influenzae type b vaccine, meningococcal conjugate vaccine, and meningococcal B vaccine should be given 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 years of age and older.

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 when younger than age 65 years will need a second dose 5 years later. At age 65 years or older, all adults (including people vaccinated when younger) are recommended to have a single dose 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?

Possibly. If you are going to give him Menactra brand MenACWY, you need to wait at least 4 weeks after he completes the PCV13 series before giving him the Menactra. There is no similar space consideration if Menveo brand MenACWY is used; it may be given simultaneously with PCV13 or at any interval before or after receipt of PCV13.

We have a 10-year-old getting renal dialysis. 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?

Recommendations to separate MenACWY and PCV13 only apply to persons with functional or anatomic asplenia or HIV (see next Q&A). In this scenario, the best schedule is to give MenACWY (either 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 or PPSV23 to a patient?

Yes, with several exceptions. PPSV23 and PCV13 are both 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 PCV13 and PPSV23 at the same time.
2.	If the person has functional or anatomic asplenia or HIV infection, observe these rules:
	•	If using Menactra brand MenACWY vaccine, you should give PCV13 first with a 4 week separation between the final dose of PCV13 and Menactra.
	•	If using Menveo brand MenACWY give PCV13 at the same visit or at any interval before or after each other.

The pneumococcal conjugate vaccine (PCV13) 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 PCV13 and influenza vaccine at the same visit?

No. The available data have been interpreted that any changes in antibody response to either vaccines' components were clinically insignificant. If PCV13 and influenza vaccine are both indicated and recommended they should be administered at the same visit. See the PCV13 ACIP recommendations, www.cdc.gov/mmwr/pdf/wk/mm6337.pdf, page 824.

What intervals should be observed between doses of PCV13 and PPSV23 for those children and adults who are recommended to receive both vaccines?

For PCV13-naïve adults ages 65 years and older, give PCV13 first followed by PPSV23 one year later. For adults at increased risk of pneumococcal disease (such as immunocompromising conditions or asplenia) give PCV13 first followed by PPSV23 in at least 8 weeks. For adults age 19 years and older who have received one or more doses of PPSV23 previously, wait one year before giving PCV13 to avoid interference between the 2 vaccines. For children age 2 through 18 years who have not received PCV13 but who have received one or more doses of PPSV23 previously, wait 8 weeks before giving PCV13.

The Zostavax vaccine (Merck) package insert says that Zostavax should not be given simultaneously with pneumococcal polysaccharide vaccine (PPSV23). What does ACIP say about this?

ACIP has not changed its recommendation on the simultaneous administration of these two vaccines (i.e., they can be given at the same time or any time before or after each other).

Administering Vaccines

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A dose of pneumococcal conjugate vaccine was administered into my patient's dialysis port. Does this dose count?

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 is recommended for administration of pneumococcal polysaccharide vaccine?

Pneumococcal polysaccharide vaccine (PPSV23) may be given either by intramuscular (IM) or subcutaneous injection. When administration is IM, choose needle length appropriate to the person's age and body mass: toddlers age 2 years: 1–1¼" (anterolateral thigh) or ⅝–1" (deltoid muscle); children ages 3–4 years: ⅝–1" (deltoid) or 1–1¼" (anterolateral thigh); adults, a 1–1½" needle. A ⅝" needle may be used in toddlers and children, adolescents and for adult patients weighing less than 130 lbs (60 kg) for IM injection in the deltoid muscle. For all of these age groups, a 5/8" needle can be used only if the subcutaneous tissue is not bunched and the injection is made at a 90-degree angle. When administration of PPSV23 is subcutaneous, a ⅝" needle is recommended.

What route and needle length should we use for administration of pneumococcal conjugate vaccine (PCV13)?

Pneumococcal conjugate vaccine (PCV13) should be administered by the intramuscular (IM) route. Choose needle length appropriate to the person's age and body mass: infants younger than age 12 months: 1"; toddlers 1–2 years: 1–1¼" (anterolateral thigh) or ⅝–1" (deltoid muscle); children ages 3–4 years: ⅝–1" (deltoid) or 1–1¼" (anterolateral thigh); adults, a 1–1½" needle. A ⅝" needle may be used in toddlers, children, adolescents, and for adult patients weighing less than 130 lbs (60 kg) for IM injection in the deltoid muscle. For all of these age groups, a 5/8" needle can be used only if the subcutaneous tissue is not bunched and the injection is made at a 90-degree angle.

How should pneumococcal vaccines be stored?

Both pneumococcal conjugate and pneumococcal polysaccharide vaccines should be refrigerated at temperatures between 2°C (35°F) and 8°C (46°F). Do not freeze either vaccine. Vaccine exposed to freezing temperature should not be administered.

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