Pneumococcal vaccines (PCV15, PCV20, PCV21 and PPSV23) in adults

The disease and why it matters

Streptococcus pneumoniae (the pneumococcus) causes pneumococcal disease; it has more than 100 known serotypes, but only a minority of serotypes produce the majority of infections. ^[1]

The more serious syndromes are pneumonia, bacteremia and meningitis; acute otitis media and sinusitis are less serious but more common. ^[1]

Spread is person to person through respiratory droplets, and the serotypes most often causing infection are those most often found in carriers. ^[1]

People at increased risk include children younger than 5 years and adults 50 years or older. Conditions that raise the risk of invasive pneumococcal disease include alcoholism, cerebrospinal fluid leak, chronic heart, kidney, liver or lung disease, cigarette smoking, cochlear implant, decreased immune function from disease or drugs, and diabetes mellitus. ^[1]

Invasive pneumococcal disease (IPD) means bacteria invading parts of the body, such as the blood, that are normally free from germs; CDC says IPD rates declined dramatically in children and adults after the United States began using pneumococcal conjugate vaccines in 2000. ^[2]

Pneumococcal infections are more common in winter and early spring, and the bacteria causing IPD are not susceptible to one or more classes of antibiotics in more than 40% of cases. ^[2]

Scope of this lesson: vaccine use in adults. Recommendations for infants, children and adolescents are in CDC's child and adolescent schedule and are not reproduced here.

Video and figures

Video

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Pneumococcus - VEC Vaccine Notes | Vaccine Education at Children’s Hospital of Philadelphia
Channel: Vaccine Education Center at CHOP · Uploaded January 14, 2026 · Confirmed available October 12, 2026 · Open on YouTubeRxEvidence has not checked every statement in this video.

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Four pneumococcal vaccines are FDA-licensed for adult use in the United States: one polysaccharide vaccine (PPSV23) and three conjugate vaccines (PCV15, PCV20, PCV21). CDC groups them the same way. ^[3]

Capvaxive's pneumonia indication, and Prevnar 20's indication for serotypes 8, 10A, 11A, 12F, 15B, 22F and 33F, were approved under accelerated approval based on opsonophagocytic activity (OPA) immune responses, and continued approval may depend on a confirmatory trial. ^{[13] [10]}

CDC notes that PCV21 contains eight serotypes not in PCV15, PCV20 or PPSV23, but lacks certain serotypes (for example serotype 4) that the other vaccines contain. ^[15]

Label sources differ in date: Pneumovax 23's label is revised 04/2021, Vaxneuvance's 06/2026 and Capvaxive's 6/2026, while the Prevnar 20 label posted on FDA's page shows a placeholder revision date and the page is marked content current as of 06/02/2023. ^{[4] [7] [13] [10] [9]}

Who should get it

FDA labeling does not use the ACIP age and risk framework: the three conjugate vaccines are labeled for adults 18 years of age and older, while ACIP recommends routine use from 50 years and risk-based use at ages 19 through 49 years. Use the ACIP schedule for who should be vaccinated and the label for what the product is licensed to do. ^{[7] [13] [3] [17]}

CDC's adult-schedule notes define the risk groups for ages 19 through 49 years. Underlying medical conditions or other risk factors: alcoholism, chronic heart, liver or lung disease, chronic renal failure, cigarette smoking, cochlear implant, congenital or acquired asplenia, CSF leak, diabetes mellitus, generalized malignancy, HIV infection, Hodgkin disease, immunodeficiencies, iatrogenic immunosuppression, leukemia, lymphoma, multiple myeloma, nephrotic syndrome, solid organ transplant, or sickle cell disease or other hemoglobinopathies. ^[17]

Vaccine choice and serotype 4: in some adult populations in the Western United States with data (Alaska, Colorado, New Mexico, Navajo Nation and Oregon) serotype 4 has caused 30% or more of invasive pneumococcal disease. In CDC's economic models, PCV21 compared with PCV20 could be more expensive and result in more IPD deaths in some cases where serotype 4 is 30% or more of IPD, and could be less expensive and save more lives in some cases where it is below 30%. CDC says it does not know if the same is seen in other Western areas that do not routinely monitor IPD. ^[15]

Dosing and schedule, including catch-up

Adults receive a single 0.5 mL dose of each product: Vaxneuvance and Prevnar 20 as a single dose in adults 18 years of age and older, Capvaxive as a single 0.5 mL dose, and Pneumovax 23 as a single 0.5 mL dose given intramuscularly or subcutaneously. ^{[7] [10] [13] [4]}

PCV20 or PCV21 completes the pneumococcal series for an adult; PCV15 is followed by one dose of PPSV23, and only one dose of PPSV23 is indicated. ^[3]

If PPSV23 is not available, one dose of PCV20 or PCV21 may be given; adults 19 years or older who received PCV15 but have not completed the PPSV23 step can finish with 1 dose of PCV20 or PCV21 if they no longer have access to PPSV23. ^{[3] [17]}

Adults aged 19 years and older who have received PCV20 or PCV21 need no additional pneumococcal vaccine dose. ^[17]

The Pneumovax 23 label states that routine revaccination of immunocompetent persons previously vaccinated with a 23-valent vaccine is not recommended. ^[4]

CDC offers PneumoRecs VaxAdvisor, a free app that provides patient-specific pneumococcal vaccine guidance, and a job aid on vaccine timing for adults. ^[3]

Administration

Pneumovax 23: give intramuscularly or subcutaneously into the deltoid muscle or lateral mid-thigh; do not inject intravascularly or intradermally, and do not mix with other vaccines in the same syringe or vial. ^[4]

Vaxneuvance: before use, hold the prefilled syringe horizontally and shake vigorously to obtain an opalescent suspension (multiple attempts may be required); do not use it if it cannot be resuspended. ^[7]

Prevnar 20: hold the prefilled syringe horizontally and shake vigorously until the vaccine is a homogeneous white suspension; do not use if it cannot be resuspended; give 0.5 mL intramuscularly using a sterile needle attached to the syringe; do not mix with other vaccines or products in the same syringe. ^[10]

Capvaxive: a colorless, clear to opalescent solution; inspect for particulate matter and discoloration, do not use if observed, and administer intramuscularly. ^[13]

In a Capvaxive study of 1,080 adults aged 50 years and older, concomitant quadrivalent influenza vaccine (QIV) produced non-inferior OPA responses for 20 of 21 serotypes; non-inferiority was not met for serotype 23B, and influenza antibody responses to the vaccine given concomitantly were non-inferior for 3 of 4 influenza strains. ^[13]

Syncope can occur with injectable vaccines; procedures should be in place to avoid injury from fainting. ^[13]

Storage and handling

The prefilled syringe tip caps and plunger stoppers of Vaxneuvance, Prevnar 20 and Capvaxive, and the vial stoppers, plunger stoppers and tip caps of Pneumovax 23, are not made with natural rubber latex. ^{[7] [10] [13] [4]}

Contraindications and precautions

• PCV15, PCV20 and PCV21: do not give to anyone with a history of severe allergic reaction (e.g., anaphylaxis) to any component of the vaccine or to diphtheria toxoid. ^{[7] [10] [13]}
• PPSV23: contraindicated in a severe allergic reaction (e.g., anaphylaxis) to any component of Pneumovax 23. ^[4]
• CDC's adult-schedule appendix lists, under PCV, a severe allergic reaction after a previous dose or to a vaccine component, and a severe allergic reaction to any diphtheria-toxoid-containing vaccine or its component; under PPSV23 it lists a severe allergic reaction after a previous dose or to a vaccine component. ^[18]
• Pneumovax 23: use caution and appropriate care for individuals with severely compromised cardiovascular or pulmonary function in whom a systemic reaction would pose a significant risk. ^[4]
• People with minor illnesses, such as a cold, may be vaccinated; people who are moderately or severely ill should usually wait until they recover. ^[19]

Safety and adverse events

In a Pneumovax 23 study in adults 65 years or older, systemic adverse reactions judged vaccine-related were more frequent after revaccination (33.1%) than after initial vaccination (21.7%). ^[4]

CDC's VIS lists redness, swelling, pain or tenderness where the shot is given, fever, loss of appetite, irritability, tiredness, headache, muscle aches, joint pain and chills after PCV, and redness, swelling, pain or tenderness, tiredness, headache, fever, chills and muscle aches after PPSV23. People sometimes faint after medical procedures including vaccination. ^{[19] [20]}

Suspected adverse reactions can be reported to VAERS at 1-800-822-7967. ^[13]

Special populations

Immunocompromised adults: CDC's list of immunocompromising conditions includes chronic renal failure, nephrotic syndrome, immunodeficiencies, iatrogenic immunosuppression, generalized malignancy, HIV infection, Hodgkin disease, leukemia, lymphoma, multiple myeloma, solid organ transplant, congenital or acquired asplenia, and sickle cell disease or other hemoglobinopathies. ^[17]

Labels warn that people with altered immunocompetence, including those on immunosuppressive therapy, may have a reduced immune response to Capvaxive, Vaxneuvance, Prevnar 20 and Pneumovax 23. ^{[13] [7] [10] [4]}

Lactation: for Prevnar 20 and Pneumovax 23 it is not known whether the vaccine is excreted in human milk, and the label advises weighing the benefits of breastfeeding with the mother's clinical need for the vaccine. ^{[10] [4]}

Pneumovax 23 is not approved for use in children less than 2 years of age, who do not develop an effective immune response to the capsular types in this polysaccharide vaccine. ^[4]

Counseling pearls for the pharmacy counter

• Ask about an allergic reaction after a previous dose of any PCV, or to any vaccine containing diphtheria toxoid (for example DTaP), and about severe, life-threatening allergies. ^[19]
• Vaccination may not protect all recipients, and Pneumovax 23 may not offer 100% protection from pneumococcal infection. ^{[13] [4]}
• Expect pain, redness, swelling or tenderness at the injection site, tiredness, headache and muscle aches; faint-prone patients should say if they feel dizzy or have vision changes or ringing in the ears. ^[19]
• Signs of a severe allergic reaction (hives, swelling of the face and throat, difficulty breathing, a fast heartbeat, dizziness, or weakness) need 9-1-1. ^[20]
• Use CDC's PneumoRecs VaxAdvisor app to work out which dose a patient needs and when. ^[3]

Common patient questions

References

1. Centers for Disease Control and Prevention. Clinical overview of pneumococcal disease. Page dated February 25, 2026. Accessed October 11, 2026. https://www.cdc.gov/pneumococcal/hcp/clinical-overview/index.html. Accessed October 11, 2026.
2. Centers for Disease Control and Prevention. Pneumococcal disease surveillance and trends. Page dated February 25, 2026. Accessed October 11, 2026. https://www.cdc.gov/pneumococcal/php/surveillance/index.html. Accessed October 11, 2026.
3. Centers for Disease Control and Prevention. Pneumococcal vaccine recommendations: information for healthcare professionals. Page dated February 25, 2026. Accessed October 11, 2026. https://www.cdc.gov/pneumococcal/hcp/vaccine-recommendations/index.html. Accessed October 11, 2026.
4. PNEUMOVAX 23 (pneumococcal vaccine polyvalent), sterile liquid vaccine for intramuscular or subcutaneous injection: prescribing information. Merck Sharp & Dohme Corp.; revised 04/2021. U.S. Food and Drug Administration. Accessed October 11, 2026. https://www.fda.gov/media/80547/download?attachment. Accessed October 11, 2026.
5. U.S. Food and Drug Administration. PNEUMOVAX 23 (STN BLA 101094), product page (content current as of 10/28/2021). Accessed October 11, 2026. https://www.fda.gov/vaccines-blood-biologics/vaccines/pneumovax-23-pneumococcal-vaccine-polyvalent. Accessed October 11, 2026.
6. U.S. Food and Drug Administration. VAXNEUVANCE (STN 125741), product page (content current as of 06/17/2026). Accessed October 11, 2026. https://www.fda.gov/vaccines-blood-biologics/vaccines/vaxneuvance. Accessed October 11, 2026.
7. VAXNEUVANCE (pneumococcal 15-valent conjugate vaccine), injectable suspension, for intramuscular use: prescribing information. Merck Sharp & Dohme LLC; revised 06/2026. U.S. Food and Drug Administration. Accessed October 11, 2026. https://www.fda.gov/media/150819/download?attachment. Accessed October 11, 2026.
8. U.S. Food and Drug Administration. BLA approval letter, Pneumococcal 15-valent Conjugate Vaccine (VAXNEUVANCE), STN BL 125741/0. July 16, 2021. Accessed October 11, 2026. https://www.fda.gov/media/150820/download?attachment. Accessed October 11, 2026.
9. U.S. Food and Drug Administration. PREVNAR 20 (STN 125731), product page (content current as of 06/02/2023). Accessed October 11, 2026. https://www.fda.gov/vaccines-blood-biologics/vaccines/prevnar-20. Accessed October 11, 2026.
10. PREVNAR 20 (pneumococcal 20-valent conjugate vaccine), suspension for intramuscular injection: prescribing information as posted on FDA's product page (revision date shown as a placeholder, "XX/202X"). Wyeth Pharmaceuticals LLC. U.S. Food and Drug Administration. Accessed October 11, 2026. https://www.fda.gov/media/149987/download?attachment. Accessed October 11, 2026.
11. U.S. Food and Drug Administration. Replacement BLA approval letter, Pneumococcal 20-valent Conjugate Vaccine (Prevnar 20), STN BL 125731 (effective approval date June 8, 2021). Accessed October 11, 2026. https://www.fda.gov/media/150021/download?attachment. Accessed October 11, 2026.
12. U.S. Food and Drug Administration. CAPVAXIVE (STN 125814), product page (content current as of 08/18/2026). Accessed October 11, 2026. https://www.fda.gov/vaccines-blood-biologics/capvaxive. Accessed October 11, 2026.
13. CAPVAXIVE (pneumococcal 21-valent conjugate vaccine), injection, for intramuscular use: prescribing information. Merck Sharp & Dohme LLC; revised 6/2026. U.S. Food and Drug Administration. Accessed October 11, 2026. https://www.fda.gov/media/179426/download?attachment. Accessed October 11, 2026.
14. U.S. Food and Drug Administration. BLA approval and accelerated approval letter, Pneumococcal 21-valent Conjugate Vaccine (CAPVAXIVE), STN BL 125814/0. June 17, 2024. Accessed October 11, 2026. https://www.fda.gov/media/179428/download?attachment. Accessed October 11, 2026.
15. Centers for Disease Control and Prevention. Summary of risk-based pneumococcal vaccination recommendations. Page dated May 8, 2026. Accessed October 11, 2026. https://www.cdc.gov/pneumococcal/hcp/vaccine-recommendations/risk-indications.html. Accessed October 11, 2026.
16. American Academy of Family Physicians. Adults 19 and older immunization schedules (adopted version; page shows no version date). Accessed October 11, 2026. https://www.aafp.org/clinical-insights/immunizations-and-vaccines/immunizations-schedules-resources/adult-immunization-schedules. Accessed October 11, 2026.
17. Centers for Disease Control and Prevention. Adult immunization schedule notes: recommendations for ages 19 years or older, United States, 2025. July 2, 2025. Accessed October 11, 2026. https://www.cdc.gov/vaccines/hcp/imz-schedules/adult-notes.html. Accessed October 11, 2026.
18. Centers for Disease Control and Prevention. Adult immunization schedule appendix: guide to contraindications and precautions, United States, 2025. July 2, 2025. Accessed October 11, 2026. https://www.cdc.gov/vaccines/hcp/imz-schedules/adult-appendix.html. Accessed October 11, 2026.
19. Centers for Disease Control and Prevention. Pneumococcal conjugate vaccine (PCV): what you need to know. Vaccine Information Statement, May 29, 2025. Accessed October 11, 2026. https://www.cdc.gov/vaccines/hcp/current-vis/pneumococcal-conjugate.html. Accessed October 11, 2026.
20. Centers for Disease Control and Prevention. Pneumococcal polysaccharide vaccine (PPSV23): what you need to know. Vaccine Information Statement, May 29, 2025. Accessed October 11, 2026. https://www.cdc.gov/vaccines/hcp/current-vis/pneumococcal-polysaccharide.html. Accessed October 11, 2026.