Updated Recommendations for Pneumococcal Vaccination

US Pharm. 2025;50(4):HS7-HS12.

ABSTRACT: Streptococcus pneumoniae is a common bacterial cause of pneumonia and meningitis. The CDC Advisory Committee on Immunization Practices (ACIP) recently expanded its age-based recommendation for a pneumococcal conjugate vaccine (PCV) to include all adults aged 50 years and older. There are three PCVs currently available in the United States: 15-valent PCV (PCV15), 20-valent PCV (PCV20), and 21-valent PCV (PCV21). The ACIP recommends pneumococcal vaccination as part of routine childhood immunizations for all children aged younger than 5 years, with a four-dose series of either PCV15 or PCV20 at ages 2 months, 4 months, 6 months, and 12 through 15 months. For adults aged 50 years and older who have never received a pneumococcal vaccine, the ACIP recommends either PCV20 or PCV21 as a one-time dose or PCV15 followed by one dose of 23-valent pneumococcal polysaccharide vaccine (PPSV23) 1 year later. There are additional risk-based recommendations for children and adults at increased risk for pneumococcal infection. For adults at risk for infection with S pneumoniae serotype 4, providers should consider PCV20 alone or PCV15 followed by PPSV23 1 year later. Pharmacists are in a key position to educate the public and other healthcare professionals about updated recommendations for pneumococcal vaccines and to advocate for their use.

Pneumococcal disease is caused by Streptococcus pneumoniae, a gram-positive, facultative anaerobic coccus typically observed in pairs or short chains.¹ S pneumoniae is part of the usual flora of the respiratory tract and is the most common bacterial cause of pneumonia during childhood; it accounts for up to one-third of cases of community-acquired pneumonia in adults and over one-half of all bacterial meningitis cases.¹

In October 2024, the CDC Advisory Committee on Immunization Practices (ACIP) expanded its recommendations for pneumococcal conjugate vaccines (PCV) to recommend a single dose of a PCV for all PCV-naïve adults aged 50 years and older, compared with the previous recommendation for adults aged 65 years and older.² The goal of this expanded age-based recommendation is to improve prevention of pneumococcal disease in those aged 50 to 64 years, particularly among demographic groups experiencing higher disease rates.² Recommendations for pneumococcal vaccines among adults aged 19 to 49 years with risk conditions for pneumococcal disease and adults previously vaccinated with PCV13 have not changed from previous recommendations.² This article reviews the available pneumococcal vaccines and the updated recommendations for their use.

Pneumococcal Vaccines

The main virulence factor of S pneumoniae is an outer polysaccharide capsule, and differences in the chemical structure of these polysaccharides have resulted in over 100 different serotypes of the bacterium.³ Although most serotypes can cause disease, only a few serotypes of S pneumoniae are responsible for most infections.¹ Pneumococcal vaccines contain antigenic capsular polysaccharides that elicit an immune response against the specific S pneumoniae serotypes from which they are derived.^1,3 There are two different types of vaccines available for the prevention of pneumococcal disease: PCVs and a pneumococcal polysaccharide vaccine (PPSV), as indicated in TABLE 1.^4-8 PPSV23 contains 23 capsular polysaccharide antigens, whereas PCV vaccines contain the number of capsular polysaccharide antigens that are included in their abbreviated name (e.g., 20 antigens for PCV20) and are each covalently linked (conjugated) to a carrier protein.^2,3 PCV7 was the first PCV licensed in the United States  in 2000, followed by PCV13 in 2010; these vaccines have been replaced by newer PCVs that contain a higher number of capsular polysaccharide antigens.^1,4 The capsular antigens and serotypes of S pneumoniae that each available vaccine protects against are indicated in FIGURE 1.²

PPSV23 induces antibody production through a T cell–independent mechanism, while the conjugate vaccines have an added benefit in that the polysaccharides are conjugated to an immunoreactive protein (all PCV products currently available in the U.S. employ CRM197, a nontoxic mutant of diphtheria toxin) that elicits a helper T-cell response and the formation of memory B cells.^3,9 Therefore, conjugate vaccines provide a longer duration of protection, a booster response, and a stronger immune response in children aged younger than 2 years.^10,11

Vaccine Recommendations

Vaccination is the most effective strategy for preventing pneumococcal disease.¹² The most recent ACIP guidelines recommend pneumococcal vaccination for all children aged younger than 5 years, children and adults at increased risk for pneumococcal disease, and all adults aged 50 years and older.^2,13,14

The CDC recommends pneumococcal vaccination with either PCV15 or PCV20 as part of routine childhood immunizations for all children aged younger than 5 years, with a recommended schedule of a four-dose series of either PCV15 or PCV20 at ages 2 months, 4 months, 6 months, and 12 through 15 months.¹³ Catch-up guidance for children is available at the CDC’s child and adolescent immunization schedule.¹³ There are additional risk-based recommendations for pneumococcal vaccines in children with any of the following conditions that increase an individual’s risk for pneumococcal disease: chronic heart disease (particularly cyanotic congenital heart disease and cardiac failure); chronic lung disease (including moderate persistent or severe persistent asthma); chronic kidney disease; maintenance dialysis; nephrotic syndrome; diabetes mellitus; cerebrospinal fluid leak; cochlear implant; chronic liver disease; or an immunocompromising condition such as HIV infection; diseases/conditions being treated with immunosuppressive drugs or radiation; congenital or acquired immunodeficiency; congenital or acquired asplenia; splenic dysfunction; or sickle cell disease or other hemoglobinopathy.^13,15

Recommendations on the use of pneumococcal vaccines in adults are summarized in TABLE 2.^2,4,13-16

Additional Considerations for Vaccine Selection

S pneumoniae serotype 4 has reemerged to cause a high percentage of invasive pneumococcal infections in adult populations, including the Navajo Nation and areas in the Western U.S. (Alaska, Colorado, New Mexico, and Oregon), with particular conditions or risk factors, including alcoholism, homelessness, injection drug use, cigarette smoking, or chronic lung disease.¹⁵ In these cases, providers should consider a recommended pneumococcal vaccine that covers serotype 4 (see FIGURE 1), with consideration given to either PCV20 alone or PCV15 followed by PPSV23 instead of PCV21.¹⁵

PneumoRecs VaxAdvisor

The CDC has a free resource (available as a mobile application and an online version) called PneumoRecs VaxAdvisor, available at www.cdc.gov/pneumococcal/hcp/vaccine-recommendations/app.html. After a patient’s age, information about pneumococcal vaccination history, and specific risk conditions are entered, this resource helps vaccine providers quickly and easily determine which pneumococcal vaccine an adult or pediatric patient needs and when.¹⁷

Monitoring and Follow-Up

The contraindications and considerations for use of pneumococcal vaccines in TABLE 1 should be taken into account before administering a vaccine.^5-8 The most common side effects experienced by individuals after receiving a pneumococcal vaccine are soreness/swelling at the site of injection, fever, headache, drowsiness, and loss of appetite.¹⁸ These effects are typically mild and subside within 2 days after administration.¹⁸ If a patient shows any signs of a severe allergic reaction, including hives, swelling, or difficulty breathing, 911 should be immediately called.¹⁸ In all cases, any possible adverse events following vaccination should be reported to the Vaccine Adverse Event Reporting System.¹⁸

Role of the Pharmacist

Pharmacists play an integral role in the prevention of pneumococcal disease. Pharmacists are well positioned to educate the public and other healthcare professionals about updated recommendations for pneumococcal vaccines, advocate for vaccination, and immunize eligible individuals. Pharmacists should be aware of the CDC’s available resources and how to use this information to make the most appropriate recommendations for pneumococcal vaccination.

REFERENCES

1. Hall E, Wodi AP, Hamborsky J, et al, eds. Epidemiology and Prevention  of Vaccine-Preventable Diseases. 14th ed. CDC. Washington, DC: Public Health Foundation; 2021.
2. Kobayashi M, Leidner A, 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):1-8.
3. Micoli F, Romano MR, Carboni F, et al. Strengths and weaknesses of pneumococcal conjugate vaccines. Glycoconj J. 2023;40:135-148.
4. CDC. Pneumococcal vaccine recommendations. www.cdc.gov/pneumococcal/hcp/vaccine-recommendations/index.html. Accessed January 17, 2025.
5. Vaxneuvance (pneumococcal 15-valent conjugate vaccine) suspension for intramuscular injection product information. Rahway, NJ: Merck & Co, Inc; May 2024.
6. Prevnar 20 (pneumococcal 20-valent conjugate vaccine) suspension for intramuscular injection product information. Philadelphia, PA: Pfizer, Inc; April 2023.
7. Capvaxive (pneumococcal 21-valent conjugate vaccine) injection for intramuscular use product information. Rahway, NJ: Merck & Co, Inc; June 2024.
8. Pneumovax 23 (pneumococcal vaccine polyvalent) sterile, liquid vaccine for intramuscular or subcutaneous injection product information. Rahway, NJ: Merck & Co, Inc; April 2023.
9. Marra F, Vadlamudi NK. Efficacy and safety of the pneumococcal conjugate-13 valent vaccine in adults. Aging Dis. 2019;10:404-418.
10. Vadlamudi NK, Chen A, Marra F. Impact of the 13-valent pneumococcal conjugate vaccine among adults: a systematic review and meta-analysis. Clin Infect Dis. 2019;69:34-49.
11. Pilishvili T, Bennett NM. Pneumococcal disease prevention among adults: strategies for the use of pneumococcal vaccines. Vaccine. 2015;33(Suppl 4):d60-d65.
12. CDC. About pneumococcal disease. www.cdc.gov/pneumococcal/about/index.html#cdc_disease_basics_prevention-prevention. Accessed January 23, 2025.
13. CDC. Recommended child and adolescent immunization schedule for ages 18 years or younger, United States, 2025. www.cdc.gov/vaccines/hcp/imz-schedules/downloads/child/0-18yrs-child-combined-schedule.pdf. Accessed January 23, 2025.
14. CDC. Recommended adult immunization schedule for ages 19 years or older, United States, 2025. www.cdc.gov/vaccines/hcp/imz-schedules/downloads/adult/adult-combined-schedule.pdf. Accessed January 23, 2025.
15. CDC. Summary of risk-based pneumococcal vaccination recommendations. www.cdc.gov/pneumococcal/hcp/vaccine-recommendations/risk-indications.html. Accessed January 17, 2025.
16. CDC. Pneumococcal vaccine timing for adults. www.cdc.gov/pneumococcal/downloads/Vaccine-Timing-Adults-JobAid.pdf. Accessed January 23, 2025.
17. CDC. PneumoRecs VaxAdvisor app for vaccine providers. www.cdc.gov/pneumococcal/hcp/vaccine-recommendations/app.html. Accessed January 17, 2025.
18. CDC. Pneumococcal vaccine safety. www.cdc.gov/vaccine-safety/vaccines/pneumococcal.html. Accessed January 17, 2025.

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