Expanded Recommendations for Use of Pneumococcal Conjugate Vaccines Among Adults Aged ≥50 Years

Publication Date: January 9, 2025
Last Updated: January 9, 2025

Summary of Recommendations

Recommendations for Use of PCV

ACIP recommended PCV for all PCV-naïve adults aged ≥50 years. Recommendations for PCVs for adults aged 19–49 years with a risk condition and for adults who have previously received PCV13 remain unchanged (Table). The recommendation was supported by several factors, including the potential to improve vaccination coverage and reduce pneumococcal disease incidence and mortality in adults aged 50–64 years, particularly among demographic groups experiencing higher disease rates. Ease of implementing consistent age-based recommendations for all PCVs was also considered. Uncertainties regarding key assumptions guiding the economic models and higher cost per QALY estimates for PCV20 compared with PCV21 were acknowledged.
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Selection of PCV in Populations with High Proportions of Serotype 4 Pneumococcal Disease

In many U.S. settings, PCV21 is expected to cover more circulating pneumococcal strains than do other recommended PCVs. In certain populations in which ≥30% of pneumococcal disease is due to serotype 4, pneumococcal vaccines that include serotype 4 (PCV20 alone or PCV15 and PPSV23 in series) (Figure) are expected to provide broader serotype coverage against locally circulating strains than does PCV21
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PPSV23 Use in PCV13-Experienced Adults Who Have Not Completed the Recommended Vaccination Series

Among adults aged ≥19 years who have started their pneumococcal vaccination series with PCV13 but have not received all recommended doses, PPSV23 is no longer recommended as an option to complete the series. Either PCV20 or PCV21 is recommended to complete the series as previously recommended. (Table).
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Coadministration with Other Vaccines

In accordance with CDC’s General Best Practice Guidelines for Immunization, routine administration of a pneumococcal vaccine with other age-appropriate doses of vaccines at the same visit is recommended for adults who have no specific contraindications to vaccination at the time of the health care visit.
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Contraindications and Precautions

Vaccination providers should consult the vaccine package insert for precautions, warnings, and contraindications. Vaccination with PCV or PPSV23 is contraindicated in persons known to have had a severe allergic reaction (e.g., anaphylaxis) to any component of the vaccine. Because PCVs are conjugated to CRM197, a nontoxic genetically altered diphtheria toxin, these vaccines are also contraindicated in persons known to have had a severe allergic reaction to any diphtheria toxoid–containing vaccine.
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Figure. Serotypes*,† included in pneumococcal vaccines currently recommended for adults — United States, 2024

Abbreviations: PCV = pneumococcal conjugate vaccine; PCV15 = 15-valent PCV; PCV20 = 20-valent PCV; PCV21 = 21-valent PCV; PPSV23 = 23-valent pneumococcal polysaccharide vaccine.
* PCV21 is approved for the prevention of invasive pneumococcal disease caused by serotype 15B based upon prespecified criteria for the proportion of participants with fourfold or more rise in opsonophagocytic activity responses. https://www.fda.gov/media/179426/download?attachment

Table. Clinical guidance for implementing pneumococcal vaccine recommendations for adults aged ≥19 years — United States, October 2024

Having trouble viewing table?
Risk or age group Vaccine received previously Options for vaccination
Adults aged ≥50 years None or PCV7 only at any age A single dose of PCV21, PCV20, or PCV15. If PCV15 is administered, a single dose of PPSV23* should be administered ≥1 year after the PCV15 dose. A minimum interval of 8 weeks can be considered if PCV15 is used in adults with an immunocompromising condition,† cochlear implant, or CSF leak.
PPSV23 only A single dose of PCV21, PCV20, or PCV15 ≥1 year after the last PPSV23 dose.
PCV13 only A single dose of PCV21 or PCV20 ≥1 year after the PCV13 dose.
PCV13 at any age and PPSV23 at age <65 years A single dose of PCV21 or PCV20 ≥5 years after the last pneumococcal vaccine dose.
PCV13 at any age and PPSV23 at age ≥65 years Shared clinical decision-making is recommended regarding administration of either a single dose of PCV21 or PCV20 for any adult aged ≥65 years who has completed the recommended vaccination series with both PCV13 and PPSV23 (i.e., PPSV23 administered at age ≥65 years) but PCV21, PCV20, or PCV15 not yet received. If a decision to administer PCV21 or PCV20 is made, a single dose is recommended ≥5 years after the last pneumococcal vaccine dose.
Adults aged 19–49 years with an immunocompromising condition,† a CSF leak, or a cochlear implant None or PCV7 only at any age A single dose of PCV21, PCV20, or PCV15. If PCV15 is used, administer a single dose of PPSV23* ≥8 weeks after the PCV15 dose.
PPSV23 only A single dose of PCV21, PCV20, or PCV15 ≥1 year after the last PPSV23 dose.
PCV13 only A single dose of PCV21 or PCV20 administered ≥1 year after the PCV13 dose.
PCV13 and 1 dose of PPSV23 A single dose of PCV21 or PCV20 ≥5 years after the last pneumococcal vaccine dose. The pneumococcal vaccination series is complete, and it need not be followed by additional pneumococcal vaccine doses.
PCV13 and 2 doses of PPSV23 The pneumococcal vaccination recommendations should be reviewed again when the person turns age 50 years. Alternatively, a single dose of either PCV21 or PCV20 should be administered ≥5 years after the last pneumococcal vaccine dose. If PCV21 or PCV20 is used, the series is complete, and it need not be followed by additional pneumococcal vaccine doses.
Adults aged 19–49 years with chronic medical conditions§ None or PCV7 only at any age A single dose of PCV21, PCV20, or PCV15. If PCV15 is administered, a single dose of PPSV23* should be administered ≥1 year after the PCV15 dose.
PPSV23 only A single dose of PCV21, PCV20, or PCV15 ≥1 year after the last PPSV23 dose.
PCV13 only A single dose of PCV21 or PCV20 ≥1 year after the PCV13 dose.
PCV13 and 1 dose of PPSV23 The pneumococcal vaccination recommendations should be reviewed again when the person reaches age 50 years.
Abbreviations: CSF = cerebrospinal fluid; PCV = pneumococcal conjugate vaccine; PCV7 = 7-valent PCV; PCV13 = 13-valent PCV; PCV15 = 15-valent PCV; PCV20 = 20-valent PCV; PCV21 = 21-valent PCV; PPSV23 = 23-valent pneumococcal polysaccharide vaccine.
* For adults who have received PCV15 but have not completed their recommended pneumococcal vaccine series with PPSV23, 1 dose of PCV21 or PCV20 may be used if PPSV23 is not available.
† Chronic renal failure, nephrotic syndrome, immunodeficiency, iatrogenic immunosuppression, generalized malignancy, HIV infection, Hodgkin disease, leukemia, lymphoma, multiple myeloma, solid organ transplant, congenital or acquired asplenia, or sickle cell disease or other hemoglobinopathies.
§ Alcoholism; chronic heart disease, including congestive heart failure and cardiomyopathies; chronic liver disease; chronic lung disease, including chronic obstructive pulmonary disease, emphysema, and asthma; cigarette smoking; or diabetes mellitus.

Box. Clinical guidance on selection of pneumococcal conjugate vaccine in communities with high percentages of serotype 4 pneumococcal disease — United States, 2024

  • PCV21 contains eight pneumococcal serotypes that are not included in previously recommended pneumococcal vaccines (i.e., PCV15, PCV20, and PPSV23). However, PCV21 does not contain certain pneumococcal serotypes that are contained in previously recommended pneumococcal vaccines, one of which is pneumococcal serotype 4.
  • In certain adult populations in the western United States, high percentages (i.e., ≥30%) of IPD caused by serotype 4 have occurred. The available IPD serotype data from CDC’s Active Bacterial Core surveillance, as well as similar surveillance from Alaska and Navajo Nation, indicate that this serotype is particularly prevalent in Alaska, Colorado, Navajo Nation, New Mexico, and Oregon. Serotype 4 IPD occurs across age groups; however, cases are frequently observed among adults aged <65 years who have underlying conditions, such as alcoholism, chronic lung disease, cigarette smoking, homelessness, and injection drug use. In such populations in these geographic areas, other recommended pneumococcal vaccines (e.g., PCV20 alone or both PCV15 and PPSV23) are expected to provide broader serotype coverage against locally circulating strains compared with PCV21.
  • The percentages of serotype 4 IPD cases in other areas of the western United States without IPD surveillance are currently unknown. IPD surveillance from other geographic areas in the United States (e.g., midwestern, eastern, and southern regions) has not detected significant percentages of serotype 4.
  • This clinical guidance will be reviewed and updated as pneumococcal disease epidemiology evolves.

Recommendation Grading

Disclaimer

The information in this patient summary should not be used as a substitute for professional medical care or advice. Contact a health care provider if you have questions about your health.

Overview

Title

Expanded Recommendations for Use of Pneumococcal Conjugate Vaccines Among Adults Aged ≥50 Years

Authoring Organization

Centers for Disease Control and Prevention

Publication Month/Year

January 9, 2025

Last Updated Month/Year

January 13, 2025

Document Type

Consensus

Country of Publication

US

Document Objectives

Before October 2024, the Advisory Committee on Immunization Practices (ACIP) recommended use of a pneumococcal conjugate vaccine (PCV) for all adults aged ≥65 years, as well as for those aged 19–64 years with risk conditions for pneumococcal disease who have not received a PCV or whose vaccination history is unknown. Options included either 20-valent PCV (PCV20; Prevnar20; Wyeth Pharmaceuticals) or 21-valent PCV (PCV21; CAPVAXIVE; Merck Sharp & Dohme) alone or 15-valent PCV (PCV15; VAXNEUVANCE; Merck Sharp & Dohme) in series with 23-valent pneumococcal polysaccharide vaccine (PPSV23; Pneumovax23; Merck Sharp & Dohme). There are additional recommendations for use of PCV20 or PCV21 for adults who started their pneumococcal vaccination series with 13-valent PCV (PCV13; Prevnar13; Wyeth Pharmaceuticals). The ACIP Pneumococcal Vaccines Work Group employed the Evidence to Recommendations framework to guide its deliberations on expanding the age-based PCV recommendation to include adults aged 50–64 years. On October 23, 2024, ACIP recommended a single dose of PCV for all PCV-naïve adults aged ≥50 years. Recommendations for PCVs among adults aged 19–49 years with risk conditions and PCV13-vaccinated adults have not changed from previous recommendations. This report summarizes evidence considered for these recommendations and provides updated clinical guidance for use of PCV.

Inclusion Criteria

Male, Female, Adult, Older adult

Health Care Settings

Ambulatory

Intended Users

Nurse, nurse practitioner, physician, physician assistant

Scope

Management, Prevention

Diseases/Conditions (MeSH)

D022242 - Pneumococcal Vaccines

Keywords

Pneumococcal vaccine, Pneumococcal Conjugate

Source Citation

Kobayashi M, Leidner AJ, Gierke R, et al. Expanded Recommendations for Use of Pneumococcal Conjugate Vaccines Among Adults Aged ≥50 Years: Recommendations of the Advisory Committee on Immunization Practices — United States, 2024. MMWR Morb Mortal Wkly Rep 2025;74:1–8. DOI: http://dx.doi.org/10.15585/mmwr.mm7401a1.