Proposed Updates to Clinical Guidance on Pneumococcal Vaccine Use 

among Adults

Miwako Kobayashi, MD, MPH

Advisory Committee on Immunization Practices

Pneumococcal Vaccines

October 19, 2022

National Center for Immunization & Respiratory Diseases
Current Recommendations

• Adults aged ≥65 years*. Adults aged ≥65 years* who have not 

previously received PCV or whose previous vaccination history is 

unknown should receive 1 dose of PCV (either PCV20 or PCV15). 

When PCV15 is used, it should be followed by a dose of PPSV23. 

• Adults with previous PPSV23 only. Adults who have only received 

PPSV23 may receive a PCV (either PCV20 or PCV15) ≥1 year after their 

last PPSV23 dose. When PCV15 is used in those with history of 

PPSV23 receipt, it need not be followed by another dose of PPSV23.

*Same recommendations for adults aged 19–64 years with certain underlying medical conditions or other risk factors. 

Kobayashi et al. MMWR 2022. https://www.cdc.gov/mmwr/volumes/71/wr/mm7104a1.htm
Questions received

• Does “who have not previously received PCV” include adults who have 

previously received PCV7?

• Wouldn’t adults who received PPSV23 only be part of adults “who have 

not previously received PCV or whose vaccination history is unknown”? 

• If an adult inadvertently received PPSV23 first instead of PCV15, is it a 

“may” or “should” for a person to complete the series with PCV15?

• If an adult aged <65 years with indications receives both PCV15 and 

PPSV23, does the person need another dose of PPSV23 in the future?

• What should we do if we do not have access to PCV15 or PCV20?
Proposed Clarifications

• Adults aged ≥65 years*. Adults aged ≥65 years* who have not previously 

received PCV13, PCV15, or PCV20 or whose previous vaccination history is 

unknown are recommended to receive 1 dose of PCV20 or PCV15. When 

PCV15 is used, it should be followed by a dose of PPSV23 to complete the 

recommended vaccine series. If PPSV23 is inadvertently given before 

PCV15, a dose of PCV15 or PCV20 should be given at least 1 year later

Footnote: If PCV15 or PCV20 is not available, a dose of PCV13 may be given followed by a dose of 

PPSV23 as previously recommended.

• Adults who received PPSV23 only. Adults who have only received PPSV23 

are recommended to receive a dose of either PCV20 or PCV15 ≥1 year 

after their last PPSV23 dose. When PCV15 is used in those with history of 

PPSV23 receipt, it need not be followed by another dose of PPSV23. 

*Same recommendations for adults aged 19 –64 years with certain underlying medical conditions or other risk factors. 
Rationale

• Recommending new PCVs for adults who previously received PCV7

• It has been at least 10 years since PCV7 was available in the U.S.

• The new PCVs cover ≥8 more pneumococcal serotypes

• The WG is proposing use of PCV20 for adults who previously received 

PCV13

• Not recommending additional doses of PPSV23 for adults who receive 

PCV15 followed by PPSV23

• HCPs have been confused by the recommendations of repeat PPSV23 

doses

• Reported coverage of PCV13 and PPSV23 among adults aged 19–64 

years with IC has been very low1.

• Unknown impact of new PCV use among children

• New pneumococcal vaccines are in advanced stages of development

HCP=healthcare providers, IC= immunocompromising conditions, 1. Deb et al. Expert Rev Vaccines 2021. 

Rationale (continued)

• Recommending PCV15 or PCV20 for adults who inadvertently 

received PPSV23 first for the PCV15–PPSV23 series

• Avoiding use of “should” vs “may”

• Similar recommendation was in place when adults were 

recommended to receive PCV13 followed by PPSV23

• Recommending either PCV15 or PCV20 for adults who have received 

PPSV23 only

• Under the new recommendations, all adults with indications for 

pneumococcal vaccines are recommended to receive a PCV

• An interval of “at least 1 year” is consistent with the PPSV23–

PCV13 sequence that was previously recommended
Proposed changes to address gaps in current 

adult pneumococcal vaccine recommendations

Hematopoietic Stem Cell Transplant Recipients
Adults who received hematopoietic stem cell transplant are 

currently not included as part of the pneumococcal risk conditions

Pneumococcal Vaccine Timing for Adults-April 1, 2022 (cdc.gov)
Existing Guidance 1. CDC’s General Best Practice 

Guidelines for Immunization

• “Sequential administration of 3 doses of pneumococcal conjugate 

vaccine is recommended, beginning 3-6 months after the transplant, 

followed by a dose of PPSV23”.

• “Some sources state a 4-week interval between these doses as 

reasonable with the dose of PPSV23 being replaced by a dose of 

PCV13 in the context of graft-versus-host disease. Other sources 

support 3 doses of PCV13 at 8-week intervals, with a dose of PPSV23 

recommended 8 weeks after the last dose of PCV13 and 12 months 

after the HSCT”.

ACIP Altered Immunocompetence Guidelines for Immunizations | CDC
Existing Guidance 2. IDSA’s Clinical Practice Guideline 

for Vaccination of the Immunocompromised Host

• “Three doses of PCV13 should be administered to adults and children 

starting at 3–6 months after HSCT (strong, low). At 12 months after 

HSCT, 1 dose of PPSV23 should be given provided the patient does 

not have chronic GVHD (strong, low). For patients with chronic GVHD, 

a fourth dose of PCV13 can be given at 12 months after HSCT (weak, 

very low).”

2013 IDSA Clinical Practice Guideline for Vaccination of the Immunocompromised Host | Clinical Infectious Diseases 

| Oxford Academic (oup.com)
Proposed updates

• Adults who are hematopoietic stem cell transplant (HSCT) recipients are 

recommended to receive three doses of PCV20 4 weeks apart starting 3 months 

after HSCT. This should be followed by a fourth PCV20 dose at least 6 months after 

the 3rd PCV20 dose, or at least 12 months after HSCT, whichever is later.

• HSCT recipients who have started their pneumococcal vaccine series with PCV13 

or PCV15 may complete their 4-dose pneumococcal vaccine series with PCV20. 

• If PCV20 is not available, three doses of PCV15 4 weeks apart, followed by a dose 

of PPSV23 at least 12 months after HSCT may be given. For patients with chronic 

graft-versus-host disease, a fourth dose of PCV15 can be given in place of 

PPSV23. 
Rationale: Use of PCV20 among HSCT recipients

• HCST recipients have poor immune response to PPSV23 when given 

during the first year of transplantation or longer, especially in those 

with chronic graft versus host disease (GVHD)1,2. 

• PCV20 currently has the broadest serotype coverage among available 

PCVs

• In this high-risk population, a regimen that provides broad 

pneumococcal serotype coverage early on is warranted

1. Hammarström V, et al. Support Care Cancer. 1993.

2. Tomblyn M. et al. Bone Marrow Transplant. 2009.
Evidence on use of 4 doses of PCV among HSCT 

recipients

• No PCV20 studies among HSCT recipients

• Two studies assessed the use of four PCV13 doses1,2:

• 3 PCV13 doses given 1 month apart followed by a booster dose 6 months 

after the 3rd PCV dose + a dose of PPSV23

• Immune responses* against the PCV13 serotypes increased from baseline to 

after the 3rd PCV13 dose, and from after the 3rd dose to after the 4th dose. 

• In one study, local and systemic reactions occurred more frequently after the 4th 

PCV13 dose, compared with after 1st–3rd dose of PCV13, but most were mild–

moderate reactions1. 

*IgG Geometric Mean Concentrations (GMC), Geometric Mean Fold Rise of GMC, and OPA titers in Cordonnier et al. 2015; serotypespecific IgG levels and proportion of patients with postimmunization IgG concentration above a certain threshold in Garcia Garrido et al. 

2022

1. Cordonnier C, et al. Clin Infect Dis. 2015

2. Garcia Garrido HM, et al. Am J Hematol. 2022
Garcia Garrido et al. AJH 2022

Serotype-specific IgG levels in mcg/ml 

over time.

T4: 2 months after 3rd PCV13 dose

T10: 2 months after 4th PCV13 dose
Cordonnier C, et al. Clin Infect Dis. 2015
Cordonnier C, et al. Clin Infect Dis. 2015
Evidence on PCV15 use among HSCT recipients

• In a phase 3 randomized controlled trial among HSCT recipients, participants 

received three doses of PCV (either PCV13 or PCV15) followed by a dose of 

PPSV23 at 12 months (or a dose of PCV13 or PCV15 in those who developed 

GVHD)

A Study to Evaluate the Safety, Tolerability, and Immunogenicity of V114 in Allogeneic Hematopoietic Stem Cell Transplant Recipients 

(V114-022/PNEU-STEM) https://ClinicalTrials.gov/show/NCT03565900
Evidence on PCV15 use among HSCT recipients

• Between those who received PCV13 or PCV15:

• Immunogenicity* was generally comparable for the 13 shared PCV13 

serotypes

• PCV15 recipients had higher immunogenicity for 2 additional serotypes not 

included in PCV13

• Injection-site adverse events and solicited systemic events were reported 

more frequently among those who received PCV15, but most were mild to 

moderate

*IgG CMG and OPA GMT

A Study to Evaluate the Safety, Tolerability, and Immunogenicity of V114 in Allogeneic Hematopoietic Stem 

Cell Transplant Recipients (V114-022/PNEU-STEM) https://ClinicalTrials.gov/show/NCT03565900
For more information, contact CDC

1-800-CDC-INFO (232-4636)

TTY: 1-888-232-6348 www.cdc.gov

The findings and conclusions in this report are those of the authors and do not necessarily represent the 

official position of the Centers for Disease Control and Prevention.

Thank You!!