Pneumococcal (PPSV23)

Adults ≥65 years (in sequential PCV + PPSV23 regimens where PCV20 not available). Adults 19–64 with risk factors: chronic heart/lung/liver disease, diabetes, alcoholism, smoking, CSF leaks, cochlear implants. Immunocompromising conditions: HIV, chronic renal failure/nephrotic syndrome, leukemia, lymphoma, Hodgkin disease, multiple myeloma, generalized malignancy, iatrogenic immunosuppression, solid organ transplant. Functional or anatomic asplenia. Residents of long-term care facilities.

Severe allergic reaction to previous dose or any component (phenol preservative). Moderate to severe acute illness (defer). No age-specific contraindications in approved range.

Very common: injection site pain (61%), swelling (21%), erythema (16%). Common: fatigue (14%), headache (17%), myalgia (12%), fever (2%). Arthus-type reaction possible with revaccination (especially if interval <5 years) — extensive limb swelling. Revaccination reactions generally more pronounced than primary. Serious adverse events: rare (<0.1%).

Single 0.5 mL dose, IM (preferred) or SC. Primary vaccination: single dose. Revaccination (single additional dose): at ≥5 years for immunocompromised, functional/anatomic asplenia, chronic renal failure, or nephrotic syndrome. Adults ≥65: single revaccination if first dose was before age 65 and ≥5 years have elapsed. Maximum 2 lifetime doses. Inject in deltoid muscle.

Observational studies: 50–80% effectiveness against invasive pneumococcal disease (IPD) from vaccine serotypes in immunocompetent adults. Limited effectiveness against non-bacteremic pneumonia (20–40%). Protection wanes over 5–10 years. No effectiveness against nasopharyngeal carriage (cannot induce herd protection). Less effective in immunocompromised patients.

Store at +2°C to +8°C. Do not freeze. Protect from light. Ready-to-use solution — no reconstitution needed. Shelf life: 24 months.

Can be co-administered with influenza, COVID-19, and other inactivated vaccines. When used sequentially with PCV13/15: administer PCV first, then PPSV23 ≥8 weeks later (immunocompromised) or ≥1 year later (immunocompetent adults ≥65y). PCV20 eliminates need for sequential PPSV23. No drug interactions.

Safe in pregnancy (inactivated polysaccharide). Limited data but no teratogenicity signal. Administer if indicated (e.g., asplenia, immunocompromised). Breastfeeding: safe.

Breastfeeding: PPSV23 (Pneumovax 23®, polysaccharide vaccine) is compatible with breastfeeding. As an inactivated vaccine, it poses no risk to the nursing infant. Anti-pneumococcal antibodies may be transferred through breast milk, providing passive protection. No interruption of breastfeeding is required.

Not approved for <2 years (T-cell independent response is poor in young children — conjugate vaccines used instead). Children ≥2 years with high-risk conditions: PPSV23 after completing PCV13/15 series (≥8 weeks later).

Primary target population (≥65 years). Immune response may be reduced compared to younger adults. Revaccination response lower than primary. Transition to PCV20 simplifies elderly immunization schedule.

T-cell independent response: does not generate memory B cells, so revaccination is limited to one additional dose (at most). Cannot prime immune system like conjugate vaccines. Do NOT confuse with PCV13/15/20 (conjugate vaccines with different immunological properties). Hyposplenic/asplenic patients: vaccinate ≥2 weeks before elective splenectomy. Current ACIP trend: PCV20 monovalent replacing PCV15+PPSV23 sequential approach.