Guidance

Pneumococcal vaccination for older adults and for individuals in a clinical risk group: Information for healthcare practitioners

Published 19 January 2026

This information for healthcare practitioner guidance is about pneumococcal vaccination for older adults and individuals in clinical risk groups.

Information about the Routine infant pneumococcal vaccination programme and the Changes to routine childhood immunisation programme: 2025 and 2026 is also available so please ensure you use the correct guidance for the programme you are delivering.

This guidance should be used in conjunction with other information sources about the adult and clinical risk group pneumococcal programme. These include the Green Book Pneumococcal chapter, the Summary of Product Characteristics (SPC) for PPV23 or PCV20, and the relevant template Patient Group Directions (PGDs), all of which should be actively consulted by those delivering this programme. All staff should have access to this guidance. We have provided inks to additional resources.

As this switch to a supply of PCV20 is a change to an already well-established programme, this guidance does not cover information that is available in the Green Book Part 1: principles, practices and procedures or other UKHSA immunisation guidance, as practitioners are expected to have received training and be knowledgeable in these areas. Instead, it focusses on those aspects of the pneumococcal programme which may generate questions in everyday practice.

The information in this guidance was correct at the time of publication. It will be updated as and when required so please only access this guidance online to ensure that you are using the latest version.

Introduction

Invasive pneumococcal disease (IPD) is a major cause of morbidity and mortality. IPD particularly affects the very young, the elderly, and those with impaired immunity and other underlying medical conditions.

The pneumococcal polysaccharide vaccine (PPV23), which protects against 23 serotypes of Streptococcus pneumoniae (the pneumococcus), has been recommended for risk groups in the UK since 1992 and, additionally, for all people aged 65 years and over since 2003.

Pneumococcal conjugate vaccines (PCVs) have been developed using polysaccharides from the most common serotypes causing invasive pneumococcal disease (IPD). Conjugating bacterial capsular polysaccharides to proteins improves the host immune response to these polysaccharides and these vaccines have proven to have very high effectiveness in preventing pneumococcal infections. Over time, the number of serotypes in these vaccines has increased and a vaccine offering protection against 20 serotypes (PCV20) is now licensed in the UK.

The UK infant pneumococcal conjugate vaccine (PCV) immunisation programme commenced in 2006 and there has been a high vaccine uptake for a number of years. This has led to large and sustained decreases in pneumococcal disease caused by the serotypes contained in the vaccines, especially in young children, but also across the population because this vaccination strategy has successfully achieved high levels of indirect (herd) protection for all age groups. Circulation of the 13 serotypes contained in the PCV13 vaccine currently given to infants – and the risk of disease due to these serotypes, even in those at higher risk – is, therefore, very low in the UK.

However, vaccination of individuals at increased risk from pneumococcal disease - older adults and individuals in a clinical risk group - remains an important element of the vaccination strategy to combat pneumococcal disease. Different schedules and vaccines are offered depending upon the degree of risk. The Joint Committee of Vaccination and Immunisation (JCVI) reviewed these aspects of the programme in June 2023.

Background to the 2026 changes to the vaccine supply

In June 2023, the JCVI advised that either PCV20 or PPV23 could be used for the adult pneumococcal programme, and for individuals over 2 years of age in a clinical risk group. It was noted that PPV23 has broader coverage due to the larger number of serotypes but that waning of immunity may occur at a slower rate when PCV20 is used.

Ministers accepted the JCVI advice in January 2024 and, following a competitive tender, Prevenar 20 (PCV20) has been procured and will begin to replace PPV23 in the national programme from early 2026. PCV20 contains the 13 serotypes in PCV13 and an additional 7 other serotypes. Details about Prevenar 20 are available in the Green Book Pneumococcal chapter and in the product’s SPC (Prevenar 20).

As well as gradually replacing PPV23 for adults from 65 years of age, and those in clinical risk groups from their second birthday, a clinical decision (noted by the JCVI in October 2025), was made to replace PCV13 with PCV20, once it became available, for primary doses for children younger than 2 years of age with asplenia, splenic dysfunction, complement deficiency or severe immunosuppression. The vaccine for the routine childhood pneumococcal vaccination programme (PCV13) remains unchanged, with the first dose given at 16 weeks of age and the second dose on their first birthday.

Once available to order, even if PPV23 stocks haven’t finished, PCV20 should be used for those aged 2 years and above with severe immunosuppression. Additionally, health protection teams may access the national supply for management of outbreaks of pneumococcal disease in closed settings. However, in order to avoid wastage, PCV20 will not be available to order for other indications until the national stock of PPV23 has been exhausted (in early 2026). If PPV23 is indicated for an individual and is available locally (in providers’ vaccine fridges), it must be used up first.

Key points and general information

Supplies

The PPV23 doses that are currently being supplied have an expiry date of 31 December 2026. As with all vaccines, when stored in a validated vaccination fridge between +2°C and +8°C, they remain effective up to and including their expiry date. Once all national stock of PPV23 has been supplied to providers, PCV20 will become available to order. However, locally held stock of PPV23 should be used up first, if PPV23 is recommended for that individual, to avoid wastage. This means that where the Green Book Pneumococcal chapter advises “PPV23 or PCV20 (when available)”, even if national stocks of PPV23 have run out and are no longer available to order, PPV23 should be given if it is in the provider’s vaccine fridge. The exception is individuals aged 2 years and above with severe immunosuppression who can receive PCV20 from when it is available to order. Note that PPV23 should not be given to any child under 2 years of age.

When PCV20 is available to order, it can replace doses of PCV13 in the schedule for children under 2 years with the following conditions only: asplenia, splenic dysfunction, complement disorder and severe immunosuppression. PCV20 should also be given from 2 years of age to individuals with severe immunosuppression. This means that where the Green Book Pneumococcal chapter advises “PCV13 or PCV20 (when available)” once PCV20 can be ordered it can be given for these indications. Individuals to whom this applies will be in receipt of secondary care and their secondary care clinicians are expected to liaise with primary care regarding their vaccination requirements.

In the event of a cluster of pneumococcal disease in a closed setting where vaccination is indicated, the local UKHSA Health Protection Team will be able to access a supply of PCV20. PCV20 should be obtained and administered in these circumstances for outbreaks caused by serotypes included in PCV20, even if PPV23 is still available to order or in local provider’s vaccine fridges at that time.

Vaccine ordering

Vaccines for the national pneumococcal immunisation programme in England should be ordered via the ImmForm website. Healthcare practitioners should refer to this website and Vaccine Update (the vaccination newsletter for healthcare practitioners) for current information on vaccine availability. There is a single supply and ordering route for all PCV20 indications.

As the programme requires a year-round rather than seasonal offer of vaccination, vaccines should be ordered regularly throughout the year to avoid delaying protection to those who are eligible. To minimise wastage due to fridge failures or expiry, healthcare practitioners are reminded to order no more than 2 weeks’ worth of stock rather than over-ordering or stockpiling vaccines.

Vaccines should be ordered, stored and monitored as described in the Green Book Chapter 3: Storage, distribution and disposal of vaccines.

National stock of pneumococcal vaccine is procured for the programme and must not be used for indications that are not covered in the Green Book. When providing advice to government about the programme, the JCVI reviews the current evidence with regard to benefit and cost-effectiveness. On the rare occasion when a clinician, following an assessment, determines that an individual who is not eligible for the national pneumococcal immunisation programme should receive a pneumococcal vaccine, the vaccine should be procured from the manufacturer. GP surgeries can reclaim the cost of the vaccine from the NHS. Vaccines supplied to practices free of charge via ImmForm cannot be used for this purpose.

Interval between doses of pneumococcal vaccine

For those who are indicated to receive more than 1 dose (children less than 2 years of age with asplenia, splenic dysfunction, a complement disorder or severe immunosuppression; individuals aged 2 years and above with severe immunosuppressed; or, individuals whose last dose was delayed and who require a second dose soon afterwards) a minimum 4 week interval should be observed between doses of pneumococcal vaccine (whether the same pneumococcal vaccine or different pneumococcal vaccines are given) to ensure boosting of protection.

However, when a vaccination error has occurred, revaccination with a full, potent dose should be offered as soon as possible (immediately after the error has been identified if the individual is still on the premises or as soon as this can be arranged) with no minimum interval between doses, to ensure that the individual is offered protection without delay. This includes situations where there has been administration of an incomplete dose or revaccination following a vaccine storage or handling issue (for example if, following a risk assessment, it is determined that a cold chain breach has diminished the potency of a vaccine that has been administered). There is no evidence to support that any theoretical risk of hyporesponsiveness translates to an increased risk of disease and the former advice about maintaining a minimum interval after PPV23 vaccination, therefore, no longer applies.

Advice about specific errors and how to manage these is provided in the Vaccination errors section of this publication.

Individuals who have previously received a different PCV vaccine

The 13-valent PCV13 is the pneumococcal vaccine currently recommended and in use for the UK routine childhood immunisation schedule. This will remain the case once PCV20 is used in the adult pneumococcal and clinical risk pneumococcal immunisation programmes. However, there are other pneumococcal conjugate vaccines (PCVs) available, with different valencies, which are in use in other countries and/or can be accessed privately in the UK. Individuals may present having previously received PCV10, PCV14, PCV15, PCV20 or PCV21.

In the routine schedule (which is also given to infants in a clinical risk group, except those with asplenia, splenic dysfunction, complement disorder and severe immunosuppression), at least 1 priming dose of PCV13, PCV14, PCV15 or PCV20 from 12 weeks of age is valid as a priming dose whilst a dose of one of these PCV vaccines at 1 year (on or after the first birthday) is valid as a booster dose.

PCV21 contains one additional serotype to PCV20. All doses of PCV21 given at the correct ages and intervals are valid.

However, PCV10 contains only 10 serotypes and does not, therefore, provide equivalent protection. For children currently less than 2 years of age and for older children in a clinical risk group (excluding asplenia, splenic dysfunction, complement disorder or severe immunosuppression), any doses of PCV10 previously received should be replaced with PCV13 according to the Vaccination of individuals with uncertain or incomplete immunisation algorithm and the ‘Infants and children vaccinated abroad’ section of Pneumococcal infant vaccination: information for healthcare practitioners.

For children currently less than 2 years of age with asplenia, splenic dysfunction, complement disorder or severe immunosuppression, doses of PCV10, PCV14, PCV15 (as well as doses of PCV13) can be replaced with PCV20 when available, (see Green Book Pneumococcal chapter Table 25.3 and further guidance below).

There is no requirement to replace doses of PCV10, PCV13, PCV14 or PCV15 given before the age of 2 years for any individual now aged 2 years or above.

Individuals who are up to date with their pneumococcal vaccinations when PCV20 becomes available

The JCVI recommendation is that either PCV20 or PPV23 can be used for the adult pneumococcal programme and that, for operational simplicity, the vaccine used in the adult programme should also be used for individuals over 2 years of age in a clinical risk group.

Therefore, individuals who have already received their eligible PPV23 dose do not need to be recalled and offered PCV20. Individuals who require 5-yearly revaccination (people who are asplenic, have splenic dysfunction or chronic kidney disease) and who receive PPV23 shortly before PCV20 becomes available should receive PCV20 at their next revaccination in 5 years’ time.

Severely immunosuppressed individuals who are aged 2 years and above and have had a dose of PCV13 since their 2nd birthday but not yet received a dose of PPV23, now need to receive 2 doses of PCV20 when available, ensuring a minimum interval of 4 weeks between all doses. They no longer require a dose of PPV23. If they have already received the previously recommended dose of PCV13 followed 4 weeks later by a dose of PPV23 since their 2nd birthday, they do not now require additional doses.

When PCV20 is available, children currently below the age of 2 years with asplenia, splenic dysfunction, complement disorder or severe immunosuppression who have already received PCV13, can be recalled to receive PCV20, as per Table 25.3 of the Green Book Pneumococcal chapter and the Vaccination of individuals in clinical risk groups section below. This includes children who were diagnosed and vaccinated with PCV13 before PCV20 became available and children who were vaccinated with PCV13 prior to receiving their diagnosis. Children with these conditions under the age of 1 year require 2 doses of PCV20 at least 4 weeks apart and children aged between 1 and 2 years require 1 dose of PCV20 to be given at least 4 weeks after their last PCV dose, irrespective of how many doses of PCV13 they have already received. It is expected that their secondary care team will liaise with primary care about their vaccination requirements.

Timing of PCV20 vaccination in children under 2

For children diagnosed with asplenia, splenic dysfunction, complement disorder or severe immunocompromise, PCV20 vaccination should commence from 8 weeks of age (refer to the schedules section).

All other children under the age of 2 years (including those in clinical risk groups other than asplenia, splenic dysfunction, complement disorder or severe immunocompromise) should follow the routine schedule (first dose of PCV13 at 16 weeks of age and a second dose at age 1 year).

Timing of PCV20 vaccination in children under 2 years

PCV20 vaccination should commence as soon as possible after diagnosis for all individuals in clinical risk groups and be offered on or soon after the 65th birthday to older adults who are not in a clinical risk group.

Individuals who have previously had pneumonia or pneumococcal disease

Pneumonia is an overarching term for any infection of the lungs. It can be caused by a number of different bacteria, viruses or fungi.

Streptococcus pneumoniae (‘pneumococcus’) is a bacterium which can cause pneumonia as well as sinusitis and otitis media, but which can also cause serious systemic infections (invasive pneumococcal disease (IPD)): bacteraemic pneumonia, septicaemia and meningitis. There are over a 100 serotypes of S. pneumoniae and recurrent infections can occur.

Therefore, a previous diagnosis of pneumonia from any cause or of localised pneumococcal infection or invasive pneumococcal disease is not a reason to withhold pneumococcal conjugate or polysaccharide vaccination from individuals who are eligible for pneumococcal vaccination as they will remain vulnerable to pneumococcal disease.

All individuals who receive pneumococcal vaccination should be advised that whilst the vaccine protects against the serotypes (strains) contained in the vaccine, they may still become unwell with another serotype or with a different bacteria, or a virus or fungus and should seek medical advice if they become unwell with pneumonia symptoms.

Eligible individuals with an unknown or incomplete immunisation history

For unimmunised or partially unimmunised individuals who present late for immunisation or have newly entered the UK, or where the vaccination history is unknown, follow the guidance in the Green Book chapters on the UK immunisation schedule and on Pneumoccocal disease (and further relevant chapters as required to bring the individual up to date as per the current UK schedule). The Vaccination of individuals with uncertain or incomplete immunisation algorithm is a useful tool that supplements (but does not replace) the guidance in the Green Book.

Co-administration

All pneumococcal vaccines may be administered at the same time as, or at any interval before or after all other vaccines, adhering to the standard guidance about injection sites and record keeping.

Prophylactic paracetamol

Prophylactic paracetamol is currently recommended when the MenB vaccine (Bexsero®) is given with the other primary immunisations (scheduled at 8 and 12 weeks of age). These may include PCV13 or PCV20 for children with asplenia, splenic dysfunction, complement disorder or severe immunocompromise as they are recommended to commence their 2-dose primary course of PCV from 8 weeks of age. There is no recommendation to give prophylactic paracetamol routinely when PCV13 or PCV20 is co-administered with other vaccines or given with MenB vaccine at age 12 months. However, no action needs to be taken if paracetamol is given prophylactically in error.

Older adults

Previously unvaccinated older adults should receive a dose of pneumococcal vaccine on or soon after their 65th birthday. Administer PPV23 if it is still available. Administer PCV20 once supplies of PPV23 (including locally held stocks) have been used up.

Individuals who present before their 65th birthday

Only individuals who are in a clinical risk group should be vaccinated before their 65th birthday. For the older adult programme, the vaccine is offered to provide protection when eligible individuals reach an age where they can derive most benefit. Recommendations for the age at which all vaccines should be administered are informed by the age-specific risk for a disease, the risk of disease complications, the ability to respond to the vaccine and the impact on spread in the population. The recommended schedules should, therefore, be followed as closely as possible.

Older adults not in a clinical risk group who have previously received a dose of PCV20

Whilst PPV23 is being supplied for the routine programme for adults aged 65 years and over, if an individual not in a risk group becomes eligible for PPV23 at age 65 years but has already received a dose of PCV20 (for example, privately or in error) they remain eligible for PPV23 and it can still be given if the individual wishes to receive it.

Ideally there should be a 4 week interval from receipt of the dose of PCV20 because the individual may then benefit from a boosting effect. However, it can be safely administered after any interval so there is no need to defer vaccination if an individual attends before 4 weeks have elapsed and they prefer not to wait. See the ‘Dose and frequency of administration’ section of the PCV20 PGD template PGD.

Once PPV23 is no longer available, an individual who is not in a clinical risk group and has received a dose of PCV20 before their 65th birthday does not require a further dose of PCV20.

If, following an individual assessment, a clinician has advised vaccination for someone because they have judged them to have an equivalent clinical risk to those whose conditions are listed in Table 25.2 of the Green Book Pneumococcal chapter, an additional dose at age 65 years is not required (see below).

Individuals in a clinical risk group turning 65 years of age

An individual who has already received the recommended doses of PPV23 or PCV20 before the age of 65 years of age because they are in a clinical risk group, does not require another dose of pneumococcal vaccine at 65 years of age, irrespective of the interval since they were last vaccinated or the pneumococcal vaccine that they received.

Individuals aged 65 years of age or older and newly diagnosed as “at clinical risk”

Individuals who have received a routine dose of PPV23 or PCV20 on or after their 65th birthday do not require a further dose of pneumococcal vaccine when they are diagnosed with a clinical risk condition.

Vaccination of individuals in clinical risk groups

Protection against IPD largely relies on herd immunity, a high level of which (against the strains contained within the vaccines) has been achieved by the success of the routine infant PCV13 immunisation programme. However, those individuals who are at increased clinical risk are offered additional protection depending on their age at diagnosis or first presentation, vaccination status and underlying condition. Infants at the greatest risk (diagnosed with asplenia, splenic dysfunction, complement disorder or severe immunosuppression) should commence their PCV vaccination schedule from 8 weeks to provide earlier protection. These recommendations are set out in the Green Book chapter 25F and explained below. Individuals in certain clinical risk groups will require additional vaccination against other diseases see the immunisation of individuals with underlying medical conditions chapter of the Green book and the relevant disease chapters of the Green Book.

How to use Table 25.3 of the Green Book Pneumococcal chapter

Table 25.3 of the Green Book Pneumococcal chapter sets out the recommended vaccines and schedules for individuals in clinical risk groups. It should be read in conjunction with the text in that chapter. It is important to choose both the correct column and the correct row. The columns are divided into 2 broad categories of risk group. The rows are divided according to the age at which the individual is either first diagnosed or first presents.

Whilst in many cases individuals will first present shortly after diagnosis, this is not always the case. Therefore, when consulting the table, staff should use the row for the current age of the individual; for example, if the individual was first diagnosed before the age of 2 years and is now aged 3 years staff should follow the advice, for the appropriate clinical condition, for individuals aged 2 years and above. There is no requirement to ‘go back’ and administer vaccines that were recommended in the first or second years of life.

For individuals who have received pneumococcal vaccination before the age of 2 years (whether routinely or because they are in a clinical risk group) the doses recommended in the columns headed ‘Booster from 2 years of age’ will boost previously generated antibodies. However, for individuals aged 2 years and above when they first present and who have never received pneumococcal vaccination before, these will be first doses, not boosters. For most people from the age of 2 years, their more mature immune system will make a good response to this single dose but for those who are severely immunosuppressed 2 doses (a minimum of 4 weeks apart) are required. Therefore, individuals who are aged 2 years and above with severe immunosuppression should receive 2 doses of PCV20 (when available) with a minimum interval of 4 weeks between doses.

Eligibility

The Green Book Pneumococcal chapter has comprehensive information about eligibility on the grounds of an individual’s medical condition. Some commonly raised issues are further addressed in this section. The list of conditions in Table 25.2 of the Green Book Pneumococcal chapter is not exhaustive and, following assessment, on a case-by-case basis, doctors may use their clinical judgement to advise vaccination of individuals with an equivalent risk.

Requests from secondary care to primary care for any vaccination not covered by the national programme should include a clear rationale and specific details of the vaccines and schedule they would like to their patient to receive. A prescription or PSD will be required. If the rationale or other details are unclear, the primary care clinician being asked to write the prescription or PSD should ask secondary care for this information because they are taking on the legal and professional responsibility for prescribing and administration of a prescription only medicine (POM). The national vaccine stock cannot be used for indications not covered by the Green Book (see Vaccine ordering section (above).

Testing antibody levels

There is no requirement to test antibody levels for any individual who has previously received vaccination and is (or, due to treatment, is about to become) at increased clinical risk. The results are not readily interpreted: absence of circulating antibodies may not indicate a lack of protection. Vaccination should proceed according to the recommendations in the Green Book Pneumococcal chapter. If a clinician chooses to test an individual’s antibody levels, they are responsible for determining how to proceed if the result is negative or equivocal. If they decide to offer additional vaccination, further testing is not recommended.

Asplenia and splenic dysfunction

It is important to understand the underlying pathology that has led to asplenia or splenic dysfunction, as this will aid an assessment regarding a patient’s eligibility. Individuals with asplenia or splenic dysfunction are at increased risk of serious infection due to encapsulated bacteria, which include pneumococcus and meningococcus, because the spleen is involved in the response to invasion by these pathogens. They should be fully vaccinated against these bacteria, according to the schedules set out in the Green Book. However, these individuals may not be immunosuppressed.

Whilst an immunosuppressive condition affecting the function of the spleen – and in some cases requiring its removal (splenectomy) – may be present, in other cases, splenic dysfunction or asplenia is a limited immunological problem specific to encapsulated bacteria only. If an individual has had their spleen removed as a result of trauma, for example, they would not be immunosuppressed but would be at increased risk of infection from, and need additional protection against, pneumococcal and meningococcal bacteria.

When there is doubt about the presence or degree of immunosuppression and whether an individual is eligible for or contraindicated to receiving specific vaccines, the patient’s treating clinician should be contacted for advice.

Haemoglobinopathies including sickle cell disease

Individuals with any haemoglobinopathy including homozygous sickle cell disease have splenic dysfunction, or, in some cases, will have had their spleen removed. They are all eligible for pneumococcal vaccination with PCV20 from the moment they are diagnosed with the condition (which may be in the first few weeks of life). For vaccination schedules see: ‘Individuals with asplenia or splenic dysfunction’ below.

Coeliac disease

Only individuals with coeliac disease who also have evidence of splenic dysfunction are eligible. Individuals with coeliac disease but no evidence of splenic dysfunction do not require pneumococcal vaccination after their 2nd birthday (children with coeliac disease should receive their routine doses of PCV13 at age 16 weeks and 1 year of age).

The prevalence of coeliac disease in the UK is 1%, and these individuals are now being diagnosed at a younger age. The aim of the risk-group pneumococcal vaccination programme is to vaccinate those most at risk and those who would be at increased risk in the coeliac group are the individuals with splenic dysfunction. Splenic dysfunction due to coeliac disease used to be more common when coeliac diagnosis was not considered or the disease was missed or diagnosed late, by which time the spleen had been affected. Now that coeliac disease is more easily diagnosed, and at an early age, splenic dysfunction is very uncommon in this patient group – so their risk of pneumococcal disease is no longer high, especially if there is no spleen involvement. For this reason, pneumococcal vaccination for individuals with coeliac disease is only indicated for those who have evidence of splenic dysfunction. For schedules for these individuals see: ‘Individuals with asplenia or splenic dysfunction’.

Planned splenectomy

It is preferable to vaccinate at least 2 weeks and ideally 4 to 6 weeks before planned splenectomy but if this is not possible the operation should never be delayed in order to increase the interval between administration of the dose of PCV and the onset of asplenia.

If the individual has only recently had a splenectomy, immunisation should preferably be delayed until at least 2 weeks following the operation because functional antibody responses may be better from this time.

Vaccination should follow the age-specific advice in the Green Book and the Schedules: ‘Individuals with asplenia or splenic dysfunction’ below.

Immunosuppression

Immunosuppression due to disease or treatment is a broad category. The degree of immunosuppression and the impact of a medical condition or treatment regime can vary considerably, including between individuals. This is a complex area and it is therefore not possible to provide an exhaustive list of conditions, treatments and dosages that apply. When there is doubt about the presence or degree of immunosuppression and whether an individual is eligible for or contraindicated to receiving specific vaccines, the patient’s treating clinician should be contacted for advice.

Most individuals with immunosuppression will require only the standard ‘clinical risk groups’ schedule (routine schedule before age 2 years and 1 dose after the 2nd birthday). Those with severe immunosuppression require additional doses.

Severe immunosuppression

Examples of conditions in this group include haematological cancers such as acute and chronic leukaemia, multiple myeloma, bone marrow transplantation, or genetic disorders affecting the immune system (such as IRAK-4, NEMO). The advice of their specialist should usually be sought. For schedules, see: ‘Individuals with severe immunosuppression’ below.

Once an individual is severely immunosuppressed their overall risk of all infections increases significantly (including from the many serotypes of pneumococcus that are not covered by the vaccines) so appropriate antibiotic prophylaxis should be considered by the clinician for such patients.

Individuals aged 2 years and above who are in another clinical risk group and who have previously received a dose of PPV23 or PCV20 since their 2nd birthday and then become severely immunosuppressed need an additional dose of PCV20 to bring them into line with the schedule for individuals from aged 2 years with severe immunosuppression as set out in Table 25.3 of the Green Book Pneumococcal chapter.

Note that individuals with asplenia or splenic dysfunction are not routinely included in this category. See: Asplenia and splenic dysfunction above for more information.

Complement disorders

The complement system comprises a cascade of proteins which are released as part of the humoral immune response (see:Immunology for Immunisation. These proteins have a variety of roles that complement the antibody response to antigens, including destroying pathogens. Disorders of the complement system are primary immunodeficiencies, the impact of which depends upon which protein is deficient.

This group includes individuals who are receiving certain complement inhibitor therapies. These are drugs used to treat a number of immune-mediated diseases, particularly those affecting the kidney.

The mode of action of some drugs in this category make the patient vulnerable to pneumococcal disease, for example, C3 inhibitors such as pegcetacoplan (Empaveli) and vaccination is therefore indicated. However, not all complement inhibitor therapies have this affect: for instance, terminal pathway inhibitors (which includes C5 inhibitors such as eculizumab and ravulizumab) act by down regulating the terminal complement component and patients are not at increased risk of pneumococcal disease. This is a rapidly expanding field and advice should always be sought from the patient’s specialist clinician with regard to the mode of action of the drug that they are prescribed and whether this puts them at risk of pneumococcal disease, noting that they may anyway be at increased risk due to their underlying pathology.

The immune response of individuals in this group will vary (degrees of immunocompromise) but they are not generally severely immunosuppressed. However, the advice of their specialist regarding their specific condition/ treatment should usually be sought.

For schedules, see: ‘Individuals in clinical risk groups’ below.

Planned immunosuppression

It is preferable to vaccinate at least 2 weeks and ideally 4 to 6 weeks before initiation of treatment such as chemotherapy or radiotherapy, but if this is not possible the treatment should never be delayed in order to increase the interval between administration of the dose of PCV and the onset of immunosuppression.

If it is not practicable to vaccinate 2 weeks before starting chemotherapy or radiotherapy, immunisation should be delayed until at least 3 months after completion of therapy to maximise vaccine response. Immunisation of these patients should not be delayed if this is likely to result in a failure to vaccinate. (Some specialists may wish to offer pneumococcal vaccination as recommended (knowing that the benefit may be limited at that point in time) and then revaccinate following completion of the immunosuppressive treatment. Primary care staff should discuss this with the individual’s specialist clinician).

Vaccination should follow the age-specific advice in the Green Book and the applicable information in the Schedules section below.

Once an individual is severely immunosuppressed their overall risk of all infections increases significantly (including from the many serotypes of pneumococcus that are not covered by the vaccines) so appropriate antibiotic prophylaxis should be a priority.

Chronic respiratory disease

Chronic respiratory disease refers to chronic lower respiratory tract disease.

Individuals in whom respiratory function may be compromised due to neurological or neuromuscular disease (such as cerebral palsy), are at increased risk of aspiration pneumonia and are eligible for pneumococcal vaccination. Some (but not all) individuals with a learning disability may be at increased risk of aspiration. An individual clinical risk assessment is required.

Individuals with asthma that is so severe as to require continuous or frequently repeated use of systemic steroids are eligible because they are immunosuppressed (as defined in the Immunosuppression section of the Green Book Pneumococcal chapter, Table 25.3). Asthma is not otherwise an indication.

For schedules, see: ‘Individuals in clinical risk groups’ below.

Cerebrospinal fluid (CSF): a potential route of entry for pneumococcal infection

Cochlear implants

Cochlear implantation is associated with an increased risk of pneumococcal disease because there is a connection formed between the outside of the body and the intracranial space (via the cochlear in the inner ear). Recurrent pneumococcal infections may occur in individuals with a cochlear implant.

Note that cochlear implantation should not be delayed to allow pre-operative pneumococcal vaccine administration; vaccination should be offered at the earliest opportunity post-operatively.

For schedules, see: ‘Individuals in clinical risk groups’ below.

CSF leaks

Leakage of CSF, for example following trauma or major skull surgery, allows infection (including pneumococcus) to enter the intracranial space which may lead to pneumococcal meningitis or septicaemia. Recurrent pneumococcal infections may occur in individuals with a CSF leak and the presence of a CSF leak is therefore an indication for pneumococcal vaccination.

For schedules, see: ‘Individuals in clinical risk groups’ below.

CSF shunts

A CSF shunt is inserted via a sterile procedure and is then sealed, so there is no opportunity for outside bacteria to enter the intracranial space or infect the shunt. CSF shunts are not intrinsically associated with an increased risk of pneumococcal disease and having had a CSF shunt inserted is not an indication for pneumococcal vaccination.

Schedules

Individuals in clinical risk groups

With the exceptions below, most individuals in a clinical risk group require only:

• routine vaccination according to their age if diagnosed or first presenting before the age of 2 years, followed by a dose of PPV23 or PCV20 (when available) from the age of 2 years
• a dose of PPV23 or PCV20 (when available) if diagnosed or first presenting from the age of 2 years, irrespective of their previous pneumococcal vaccination history

Most individuals with immunosuppression will fall into this group.

Individuals with asplenia or splenic dysfunction

The guidance in the Green Book Pneumococcal chapter Table 25.3 for ‘individuals with asplenia, splenic dysfunction, complement disorder or severe immunocompromise’ should be followed, noting that:

1. Because of their high risk, young children with these diagnoses should be given the maximum available protection by receiving PCV20 (containing the additional 7 serotypes that are not in PCV13); PCV20 can replace PCV13 in their infant schedule when it is available to order - the course of vaccination is different to the routine schedule for these children: 2 doses of PCV13 (PCV20 when available), given a minimum of 4 weeks apart are required for children diagnosed in infancy; vaccination should commence from 8 weeks of age (but no earlier) or as soon as possible thereafter
2. when PCV20 is available, children younger than 2 years of age with one of these diagnoses and who are partially or wholly unimmunised for their age should receive PCV20 instead of PCV13 for all outstanding doses and:
   • if PCV20 first becomes available following administration of the first dose of PCV13 to a child under 1 year of age, they should complete the 2 dose course with PCV20 (instead of PCV13) and receive an additional dose of PCV20 a minimum of 4 weeks later. These children will therefore receive 1 dose of PCV13 and 2 doses of PCV20 in their first year. They should also receive a dose of PCV20 on or shortly after their 1st birthday, observing a minimum 4 week interval since their previous dose
   • children under 1 year of age who have already received 2 doses of PCV13 should also receive 2 doses of PCV20 in their first year. These should be administered, a minimum of 4 weeks apart, commencing 4 weeks after their last dose of PCV13. These children will therefore receive 2 doses of PCV13 and 2 doses of PCV20 in their first year. They should also receive a dose of PCV20 on or shortly after their 1st birthday, observing a 4 week minimum interval since their previous dose
   • children aged 1 to 2 years of age who have already received their 1 year booster dose of PCV13 should also receive a dose of PCV20, again observing a 4 week minimum interval since their previous dose. These children will therefore receive 1 dose of PCV13 and 1 dose of PCV20 in their second year
3. Children under the age of 2 years who have received their routine doses of PCV13 before they are diagnosed with one of these conditions should be revaccinated with PCV20, commencing 4 weeks after their last dose of PCV13: 2 doses, 4 weeks apart if they are less than one year of age and have had their 16 week dose of PCV13; and 1 dose of PCV20 if they are aged between one and 2 years and have received their one year dose of PCV13; see Table 25.3 of the Green Book Pneumococcal chapter
4. Antibody levels are likely to decline rapidly in individuals with asplenia and splenic dysfunction and, therefore, re-immunisation with PPV23 or PCV20 (when available) is recommended every 5 years in these groups; testing of antibody levels prior to vaccination is not required

Individuals with complement disorder

The guidance in the Green Book Pneumococcal chapter Table 25.3 for ‘individuals with asplenia, splenic dysfunction, complement disorder or severe immunocompromise’ should be followed, noting that:

1. Because of their high risk, young children with these diagnoses should be given the maximum available protection by receiving PCV20 (containing the additional 7 serotypes that are not in PCV13); PCV20 can replace PCV13 in their infant schedule when it is available to order
2. 2 doses of PCV13 (PCV20 when available), given a minimum of 4 weeks apart are required for children diagnosed in infancy; vaccination should commence from 8 weeks of age (but no earlier) or as soon as possible thereafter
3. When PCV20 is available, children of less than 2 years of age with one of these diagnoses and who are partially or wholly unimmunised for their age should receive PCV20 instead of PCV13 for all outstanding doses and:
   • if PCV20 first becomes available following administration of the first dose of PCV13 to a child under 1 year of age, they should complete the 2 dose course with PCV20 (instead of PCV13) and receive an additional dose of PCV20 a minimum of 4 weeks later. These children will therefore receive 1 dose of PCV13 and 2 doses of PCV20 in their first year. They should also receive a dose of PCV20 on or shortly after their 1st birthday, observing a minimum 4 week interval since their previous dose
   • children under 1 year of age who have already received 2 doses of PCV13 should also receive 2 doses of PCV20 in their first year. These should be administered, a minimum of 4 weeks apart, commencing 4 weeks after their last dose of PCV13. These children will therefore receive 2 doses of PCV13 and 2 doses of PCV20 in their first year. They should also receive a dose of PCV20 on or shortly after their 1st birthday, observing a 4 week minimum interval since their previous dose
   • children aged 1 to 2 years of age who have already received their 1 year booster dose of PCV13 should also receive a dose of PCV20, again observing a 4 week minimum interval since their previous dose. These children will therefore receive 1 dose of PCV13 and 1 dose of PCV20 in their second year
4. Children under the age of 2 years who have received their routine doses of PCV13 before they are diagnosed with one of these conditions should be revaccinated with PCV20, commencing 4 weeks after their last dose of PCV13: 2 doses, 4 weeks apart if they are less than one year of age and have had their 16 week dose of PCV13; and 1 dose of PCV20 if they are aged between one and 2 years and have received their one year dose of PCV13; see Table 25.3 of the Green Book Pneumococcal chapter

These individuals do not require 5 yearly booster doses.

Individuals with severe immunosuppression

The guidance in the Green Book Pneumococcal chapter Table 25.3 for individuals with ‘asplenia, splenic dysfunction, complement disorder or severe immunocompromise’ should be followed, noting that:

1. Because of their high risk, young children with these diagnoses should be given the maximum available protection by receiving PCV20 (containing the additional 7 serotypes that are not in PCV13); PCV20 can replace PCV13 in their infant schedule when it is available to order
2. 2 doses of PCV13 (PCV20 when available), given a minimum of 4 weeks apart are required for children diagnosed in infancy; vaccination should commence from 8 weeks of age (but no earlier) or as soon as possible thereafter
3. When PCV20 is available, children of less than 2 years of age with one of these diagnoses and who are partially or wholly unimmunised for their age should receive PCV20 instead of PCV13 for all outstanding doses and:
   • if PCV20 first becomes available following administration of the first dose of PCV13 to a child under 1 year of age, they should complete the 2 dose course with PCV20 (instead of PCV13) and receive an additional dose of PCV20 a minimum of 4 weeks later. These children will therefore receive 1 dose of PCV13 and 2 doses of PCV20 in their first year. They should also receive 2 doses of PCV20 on or shortly after their 1st birthday, observing minimum 4 week intervals between all doses
   • children under 1 year of age who have already received 2 doses of PCV13 should also receive 2 doses of PCV20 in their first year. These should be administered, a minimum of 4 weeks apart, commencing 4 weeks after their last dose of PCV13. These children will therefore receive 2 doses of PCV13 and 2 doses of PCV20 in their first year. They should also receive 2 doses of PCV20 on or shortly after their 1st birthday, observing minimum 4 week intervals between all doses
   • children aged 1 to 2 years of age who have already received their 1 year booster dose of PCV13 should also receive a dose of PCV20, again observing a 4 week minimum interval since their previous dose, followed by a second dose a minimum of 4 weeks later. These children will therefore receive 1 dose of PCV13 and 2 doses of PCV20 in their second year. They no longer require PPV23
4. Children under the age of 2 years who have received their routine doses of PCV13 before they are diagnosed with one of these conditions should be revaccinated with PCV20, commencing 4 weeks after their last dose of PCV13: 2 doses, 4 weeks apart if they are less than one year of age and have had their 16 week dose of PCV13; and 2 doses of PCV20 if they are aged between one and 2 years and have received their one year dose of PCV13; see Table 25.3 of the Green Book Pneumococcal chapter
5. Upon turning 2 years of age, or if first diagnosed or presenting at any time after the 2nd birthday, a dose of PCV13 or PCV20 (once this is available to order) followed a minimum of 4 weeks later, by a dose of PPV23 or PCV20 (once available to order), with a minimum of 4 weeks between them, should be given to all individuals in this risk group. As the supply transitions, some individuals will receive a mixed schedule: whilst others will receive 2 doses of PCV20. This is acceptable and there is no requirement to recall individuals with severe immunosuppression to replace any doses of PCV13 or PPV23 that they have already received since their 2nd birthday. The switch to using PCV20 for both doses for those newly diagnosed or diagnosed and reaching their 2nd birthday should be made as soon as PCV20 becomes available to order for individuals with severe immunosuppression

These individuals do not require 5 yearly booster doses.

Individuals with leukaemia

Vaccination should be given according to their age, commencing from 6 months after completion of chemotherapy (Green Book Pneumococcal chapter, Table 25.3). The advice of their specialist should be sought.

Individuals who have had a bone marrow transplant

Vaccination of these individuals should begin 9 to 12 months following transplantation. They should be offered 2 doses of PCV13 or PCV20 (when available) at a minimum interval of 4 weeks followed by a dose of PPV23 or PCV20 (when available) at least 4 weeks later. The advice of their specialist should be sought.

Individuals with chronic kidney disease

The guidance in the Green Book Pneumococcal chapter Table 25.3 for individuals ‘at clinical risk (excluding those with asplenia, splenic dysfunction, complement disorder or severe immunocompromise)’ should be followed, noting that:

• antibody levels are likely to decline rapidly in individuals with chronic renal disease and, therefore, re-immunisation with PPV23 or PCV20 (when available) is recommended every 5 years in these groups. Testing of antibody levels prior to vaccination is not required.

Vaccination errors

Infants with asplenia, splenic dysfunction, complement disorder or severe immunocompromise given PCV13 or PCV20 before 8 weeks

Although PCVs are licensed from the age of 6 weeks, doses given too early are unlikely to be sufficiently immunogenic and offer enough protection to infants at the highest risk. This dose should therefore be discounted. Vaccination should recommence from 8 weeks. Although the preferred interval between doses of pneumococcal vaccine is usually 4 weeks, in this case, in order to provide the child with protection as soon as they can mount an adequate immune response, no minimum interval is required between the dose given too early and the replacement dose. PCV20 can replace PCV13 from when it is available to order.

Infants in a clinical risk group (not asplenia, splenic dysfunction, complement disorder or severe immunocompromise) given PCV13 before 16 weeks

Doses given after 12 weeks will stimulate an immune response and do not need to be repeated. Infants who receive their dose of PCV13 before 12 weeks of age should be offered a further dose of PCV13 at their third routine vaccination visit (usually scheduled at 16 weeks).

Too short an interval (less than 4 weeks) between any 2 doses of pneumococcal vaccination.

Most inactivated vaccines should not usually be administered at an interval of less than 4 weeks. Therefore, when the same pneumococcal vaccines have been given less than 4 weeks apart, a further dose of the same vaccine should be given 4 weeks after the incorrectly administered dose. Vaccine recipients should be advised that this may lead to an increased reactogenicity.

Infants and children aged less than 2 years with asplenia, splenic dysfunction, complement disorder or severe immunosuppression inadvertently given PCV13 instead of PCV20

A replacement dose of PCV20 should be administered as soon as practical even if this is within 4 weeks of the individual receiving the dose of PCV13 given in error. This will provide earlier protection against the additional serotypes in PCV20 compared to PCV13.

Infants and children aged less than 2 years in a clinical risk group (excluding asplenia, splenic dysfunction, complement disorder or severe immunosuppression) inadvertently given PCV20 instead of PCV13

PCV20 contains all 13 of the serotypes that are in PCV13 and so this dose does not need replacing. PCV13 should be administered for any remaining doses required under the age of 2 years.

Pneumococcal Polysaccharide Vaccine (PPV) given in error instead of Pneumococcal Conjugate Vaccine (PCV) to a child less than 2 years of age

PPV23 is not immunogenic in younger children. If PPV23 is inadvertently given to a child less than 2 years of age in error, a dose of the appropriate conjugate vaccine should be administered as soon as possible after the error is realised. There is no need to observe any particular interval between the 2 vaccine doses. Although a 4 week interval is preferred between any 2 doses of pneumococcal vaccine, in this case the individual has not been offered a vaccine which would provide them with the appropriate level of protection and the error should be corrected as soon as possible.

Pneumococcal Polysaccharide Vaccine (PPV) given in error instead of Pneumococcal Conjugate Vaccine (PCV) to an individual aged 2 years or older with severe immunosuppression

A dose of PCV13 (PCV20 when available) is recommended for individuals with severe immunosuppression on or shortly after their 2nd birthday or when first diagnosed or presenting as severely immunosuppressed from 2 years of age. A further dose of PCV20, when available, should also be administered a minimum of 4 weeks’ later. If a dose of PPV23 is given in error for either dose it should be replaced by a dose of PCV20, administered as soon as possible after the error is realised. There is no need to observe any particular interval between the 2 vaccine doses. Although a 4 week interval is preferred between any 2 doses of pneumococcal vaccine, in this case the individual has not been offered the appropriate level of protection and the error should be corrected as soon as possible.

PCV13 given instead of PPV23 or PCV20 to an at risk individual aged 2 years and above

If PCV13 is inadvertently given to an eligible at risk individual, aged 2 years and above, when PPV23 should have been administered (or, when available and PPV23 supplies have all been used up, PCV20), the dose of PPV23 (or PCV20) should be given as soon as possible after the error is realised. There is no need to observe any particular interval between the 2 vaccine doses. Although a 4 week interval is preferred between any 2 doses of pneumococcal vaccine, in this case the individual has not been offered the appropriate level of protection and the error should be corrected as soon as possible. Vaccine recipients should be advised that this may lead to an increased risk of adverse reaction.

Note that an individual who is severely immunosuppressed and aged 2 years and above should receive a dose of PCV13 (PCV20 when available) followed 4 weeks later by another dose of PPV23 or PCV20 (when available).

Resources

These have been updated to reflect the changes, including the Immunisation against infectious disease the Green Book, the Vaccination of individuals with uncertain or incomplete immunisation algorithm, the Complete routine and Routine childhood schedules, A visual guide to vaccines and the PGD templates.

Document History

Version number	Change details	Date
01.00	New information document created	January 2026