Public Health Agency of Canada. Pneumococcal vaccine: Canadian Immunization Guide. Government of Canada. Updated October 2016. Accessed October 2020. https://www.canada.ca/en/public-health/services/publications/healthy-living/canadian-immunization-guide-part-4-active-vaccines/page-16-pneumococcal-vaccine.html
Specific vaccination recommendations vary among countries or even within a given country. Local or country-specific guidelines should be consulted.
1. Vaccines: 13-valent pneumococcal conjugate vaccine (PCV-13) and 23-valent pneumococcal polysaccharide vaccine (PPSV-23) contain purified polysaccharide antigens derived from, respectively, the 13 and 23 most common serologic types of Streptococcus pneumoniae. 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; hematopoietic stem cell transplant (recipient); solid organ or islet transplant (candidate or recipient).
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.
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-13 and PPSV-23: 1 dose administered IM or subcutaneously.
A second dose of PPSV-23 vaccine 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 failure or nephrotic syndrome; and immunosuppression related to disease or therapy (ie, individuals at highest risk of invasive pneumococcal disease). If a booster dose of PPSV-23 is recommended, it should be administered ≥5 years after any previous dose of PPSV-23.
Immunization schedule in patients from selected risk groups (with immunodeficiencies, including chronic kidney disease, nephrotic syndrome, functional or anatomic asplenia, a CSF leak, or a cochlear implant) with the exception of hematopoietic stem cell transplant:
1) Patients who have received no prior pneumococcal vaccination: Start with PCV-13 and add 1 dose of PPSV-23 after ≥8 weeks to extend the protection (this sequence of vaccinations results in higher levels of specific antibodies); the booster dose of PPSV–23 should be administered as described above.
2) Patients who have previously received ≥1 dose of PPSV-23: Administration of 1 dose of PCV-13 is recommended ≥12 months after the last PPSV-23 dose; in patients in whom administration of a booster dose of PPSV-23 is necessary (see above), it should be administered ≥8 weeks after PCV-13 and ≥5 years after the first PPSV-23 dose.
For patients with a hematopoietic stem cell transplant, the following is recommended in Canada: 3 doses of PCV-13 starting 3 to 9 months after transplant administered ≥4 weeks apart; 1 dose of PPSV-23 administered 12 to 18 months after transplant (6-12 months after the last dose of PCV-13); and 1 booster dose of PPSV-23 vaccine recommended as early as 1 year later by some experts.
One dose of PPSV-23 should be administered to all adults aged ≥65 years, regardless of risk factors or previous pneumococcal vaccination. For adults who received PPSV-23 before 65 years of age, an additional dose of PPSV-23 should be administered at 65 years of age, ≥5 years after any previous dose.
Immunization with PCV-13 may be considered for pneumococcal vaccine–naive adults ≥65 years using the same approach as described for high-risk groups above, that is, PCV-13 should be provided first and followed by PPSV-23 ≥8 weeks later. Adults aged ≥65 years who have previously received PPSV-23 can receive PCV-13 if ≥1 year has passed since immunization with PPSV-23.