Pneumococcal Vaccines for Adults: The 2023 ACIP Recommendations, Explained

For years, protecting adults against pneumococcal disease meant a complicated series of two different vaccines. In 2021 the Food and Drug Administration licensed two new pneumococcal conjugate vaccines for adults, PCV15 and PCV20, and CDC's Advisory Committee on Immunization Practices (ACIP) rebuilt the recommendations around them. The 2023 report gathers every current ACIP recommendation for adults aged 19 and older, with CDC's guidance for putting them into practice.

The disease

Streptococcus pneumoniae (pneumococcus) lives in the upper airway, most often of young children, and spreads through respiratory droplets. In some people it invades normally sterile sites — pneumonia with bacteria in the blood, meningitis, bone and joint infections — which is called invasive pneumococcal disease (IPD). In adults, pneumococcal pneumonia is the most common form, and pneumococcus is the most common bacterial cause of pneumonia that puts people in hospital.

• Risk rises with age: in 2019, IPD incidence ranged from 2.3 per 100,000 among adults aged 18–34 to 37.8 among those 85 and older.
• There are at least 100 serotypes. In 2018–2019, the 24 serotypes covered by the available vaccines caused about 60–75 percent of adult IPD.
• IPD fell sharply in 2020 as COVID-19 measures cut respiratory virus circulation — 58 percent below expected for all ages in March–December 2020 — then rose again as measures were relaxed.

Who should be vaccinated

All adults aged 65 and older, and adults aged 19–64 with certain conditions or risk factors:

Obesity, homelessness and welding have been linked to higher risk in some reports but are not part of the recommendations.

What to give

Timing when PCV15 is followed by PPSV23: at least 1 year apart; a minimum of 8 weeks can be considered for adults with an immunocompromising condition, a CSF leak or a cochlear implant. The two should not be given at the same visit. If PPSV23 is given first by mistake, follow it with PCV15 or PCV20 at least a year later.

Shared clinical decision-making means the vaccine is not recommended for everyone in the group; the provider and patient decide together.

Stem cell transplant recipients

Adults who have received a hematopoietic stem cell transplant should get four doses of PCV20: three doses 4 weeks apart starting 3–6 months after transplant, and a fourth at least 6 months after the third or at least 12 months after transplant, whichever is later. Without PCV20, three doses of PCV15 can be followed by PPSV23 at least a year after transplant — or, for patients with chronic graft-versus-host disease, a fourth PCV15 dose, since they respond poorly to PPSV23.

Why these vaccines

In clinical trials, PCV15 and PCV20 produced immune responses in previously unvaccinated older adults that were noninferior to PCV13, PPSV23 or both, with safety comparable to PCV13. PCV15 is paired with PPSV23 to cover more serotypes. Economic models found PCV20 alone for adults 65 and older ranged from cost saving to $42,000 per quality-adjusted life-year gained.

Coverage lags

Among Medicare beneficiaries 65 and older, PCV13 coverage rose from 3 percent in 2014 to 49 percent in 2019. But in 2018 only 23 percent of adults aged 19–64 at increased risk had ever received a pneumococcal vaccine, and Hispanic adults have consistently had lower coverage than other groups.

Contraindications and pregnancy

Pneumococcal vaccines should not be given to anyone with a known severe allergic reaction, such as anaphylaxis, to a vaccine component; conjugate vaccines are also contraindicated after a severe allergic reaction to any diphtheria toxoid–containing vaccine. ACIP has made no recommendation on pneumococcal vaccines in pregnancy.

Sources

Based on "Pneumococcal Vaccine for Adults Aged ≥19 Years: Recommendations of the Advisory Committee on Immunization Practices, United States, 2023," by Miwako Kobayashi and colleagues, MMWR Recommendations and Reports, Centers for Disease Control and Prevention; a work of the United States government in the public domain. It updates and replaces ACIP's earlier adult pneumococcal recommendations; the recommendations were approved at ACIP's October 19, 2022 meeting.