Vaccines: Pneumococcal Infections

Specific vaccination recommendations vary among countries or even within a given country. Local or country-specific guidelines should be consulted.

1. Vaccines: The 20-valent pneumococcal conjugate vaccine (PCV-20) and 23-valent pneumococcal polysaccharide vaccine (PPSV-23) contain purified polysaccharide antigens derived from the 20 and 23 most common serologic types of Streptococcus pneumoniae, respectively. In the conjugated vaccine the antigens are attached to a carrier protein, which causes a stronger and more durable immune response. Both vaccines are inactivated.

2. Indications in adults: Vaccination is recommended in:

1) Persons aged ≥65 years.

2) All smoking adults (additionally provide smoking cessation counseling [see Nicotine Addiction]).

3) Persons from high-risk groups:

a) Patients with chronic heart disease (except for hypertension), respiratory disease (including asthma requiring medical care in the preceding 12 months, chronic obstructive pulmonary disease, and emphysema), heart disease, liver disease, diabetes mellitus, chronic neurologic conditions that may impair clearance of oral secretions, nephrotic syndrome, or renal failure (particularly those treated with peritoneal dialysis).

b) Patients with alcohol addiction.

c) Patients with congenital immunodeficiencies involving any part of the immune system, including B-lymphocyte (humoral) immunity, T-lymphocyte (cell)-mediated immunity, complement system (properdin or factor D deficiency), or phagocytic functions; immunocompromising therapy, including use of long-term glucocorticoids, chemotherapy, radiation therapy, and post–organ transplant therapy; HIV infection; malignant neoplasms including leukemia and lymphoma; as well as hematopoietic stem cell transplant (HSCT) recipients and solid organ or islet transplant candidates or recipients.

d) Patients after sickle cell disease, congenital or acquired asplenia, or splenic dysfunction (optimally vaccination should be performed ≥2 weeks before elective splenectomy).

e) Patients with a cerebrospinal fluid (CSF) leak.

f) Patients with a cochlear implant or scheduled cochlear implantation.

g) Patients after solid organ transplant.

h) Individuals who are underhoused/experiencing homelessness, who live in communities or settings experiencing sustained high invasive pneumococcal disease rates, and who are in residential care including long-term care homes and residential care homes for children with complex medical needs.

3. Contraindications: Pneumococcal vaccines are contraindicated in persons with a history of anaphylaxis after previous administration of the vaccine and in persons with proven immediate or anaphylactic hypersensitivity to any component of the vaccine.

4. Immunization schedule: PCV-20 and PPSV-23: 1 dose administered IM or subcutaneously.

A second dose of PPSV-23 is recommended for individuals of any age in whom antibody response is decreased due to functional or anatomic hyposplenia or asplenia, including sickle cell disease; chronic liver disease, including hepatic cirrhosis; chronic kidney disease or nephrotic syndrome; and immunosuppression related to disease or therapy (ie, individuals at highest risk of invasive pneumococcal disease [IPD]). If a booster dose of PPSV-23 is recommended, it should be administered ≥5 years after any previous dose of PPSV-23.

Immunization for adults without medical or environmental IPD risk factors (aged ≥18 years):

1) One dose of PCV-20 should be offered to all adults 65 years of age regardless of their pneumococcal vaccination status with PCV-13 or PPSV-23. In previously immunized adults aged ≥65 years, PCV-20 should be provided ≥1 year from either the last PCV-13 dose or the last PPSV-23 dose. However, a longer interval of 5 years between PPSV-23 and PCV-20 may maximize the total duration of protection against pneumococcal infection by taking advantage of the estimated duration of effectiveness of PPSV-23 and the boosting anticipated with PCV-20. An interval of 1 year between PCV-13 and PCV-20 is meant to expand the serotype coverage offered by PCV-13 in a time-effective manner.

2) Immunization with a 15-valent pneumococcal conjugate vaccine (PCV-15) followed by PPSV-23 may be offered as an alternative to PCV-20. PCV-15 should be provided first, followed by PPSV-23 ≥8 weeks later. For adults aged ≥65 years who have received PPSV-23 alone, when PCV-20 is not available, there may be benefit to offering immunization with PCV-15 ≥1 year after the receipt of PPSV-23.

Immunization for adults with medical or environmental IPD risk factors (aged ≥18 years):

1) Regardless of their PCV-13 or PPSV-23 vaccination status, one dose of PCV-20 is recommended for all adults aged ≥65 years and adults aged 18 to 64 years living with specific IPD risk factors.

2) For vaccine-naïve adults in whom PCV-20 is recommended, PCV-15 followed by PPSV-23 may be offered as an alternative. For adults aged ≥65 years who have received PPSV-23 alone, there may be a benefit to offering PCV-15 if PCV-20 is not available.

3) While the recommended interval between PCV-15 and PPSV-23 is 1 year, when a rapid completion of a vaccine series in a vulnerable population is required, the recommended interval is 8 weeks. The minimum interval between PCV-20 and PCV-13 is 8 weeks.

Recommended immunization in patients with HSCT in Canada:

1) HSCT recipients should be immunized with PCV-20. The specific timing of PCV-20 for HSCT recipients should be determined in consultation with the recipient’s transplant specialist.

2) Pneumococcal vaccination should be started at 3 to 9 months after HSCT with 3 doses of PCV-20 administered ≥4 weeks apart, followed by 1 dose of PCV-20 12 to 18 months post transplant (6-12 months after the last dose of PCV-20) or when the HSCT recipient reaches 2 years of age.

3) In adults, the use of PCV-15 with PPSV-23 may be considered if PCV-20 is unavailable or inaccessible to ensure HSCT recipients receive optimal protection.

4) HSCT recipients who have completed their recommended immunization schedule with PCV-13 or PCV-15 should receive one dose of PCV-20 at a minimum interval of 8 weeks since the last dose of PCV or ≥1 year since a dose of PPSV-23.