Experts Urge Pneumococcal Vaccination for Older Patients With Chronic Respiratory Disease

Elderly people with chronic respiratory diseases (CRD)—including COPD, asthma, bronchiectasis, and lung cancer—face a substantially elevated risk of pneumococcal infection, according to a new expert consensus statement published in Aging Medicine by the Respiratory Group of the Chinese Geriatrics Society.¹

The consensus, which reviewed domestic and international evidence on influenza and pneumococcal vaccination in elderly patients with CRD, found that individuals 65 years and older with CRD have a pneumococcal pneumonia incidence 2.7 times greater than those aged 50 to 64 years and 7.7 times greater than age-matched adults without CRD.¹ The findings arrive alongside updated pneumococcal vaccination guidance from the CDC, which continues to list chronic lung disease among the clinical indications for vaccination.²

For pharmacists, who are often the most accessible point of contact for adult immunization, the data reinforce a persistent gap between what guidelines recommend and what patients with chronic lung conditions actually receive.

Chronic Respiratory Disease Raises Pneumococcal Risk

CRD, which the consensus authors defined as encompassing COPD, asthma, bronchiectasis, and primary bronchogenic carcinoma, ranks as the third leading cause of death worldwide, with global cases rising 39.8% and mortality rising 28.5% between 1990 and 2019. COPD is the most common CRD among the elderly. In China alone, an estimated 100 million people have the condition, with prevalence reaching 21.2% among those aged 60 to 69 years and 35.5% among those 70 years and older.¹

The consensus cites a US cohort study showing that community-acquired pneumonia (CAP) incidence among patients with COPD reaches 9369 per 100,000, compared with 509 per 100,000 in patients without COPD—a gap that widens further with age, reaching 20,817 per 100,000 among patients with COPD aged 65 years and older.¹

A separate review of pneumococcal vaccination in CRD similarly reported that CAP incidence is more than 20-fold higher in patients with COPD (22.4 per 1000 person-years) than in the general population (1.07-1.2 per 1000 person-years) and that pneumonia, COPD, and asthma together account for 55.7% of respiratory hospital admissions and 47.3% of respiratory deaths in the European Union.³

Risk extends beyond COPD. Elderly patients with asthma show pneumococcal pneumonia incidence 3.2 times higher than those aged 50 to 64 years and 5.9 times higher than age-matched adults without asthma, per a German study cited in the consensus. In bronchiectasis, a study of 865 patients found that 62% of those infected with influenza required hospitalization, and pneumococci were detected in 30.6% of pneumonia samples from patients with bronchiectasis, compared with 8.1% in those without the condition.¹

Among patients with lung cancer, a Canadian investigation found a 13.4-times higher risk of invasive pneumococcal disease compared with the general population.¹

Vaccine Efficacy and Safety Data Support Use Across Subtypes

Evidence reviewed in the consensus and in a related review on pneumococcal vaccination and chronic respiratory disease supports both the immunogenicity and clinical benefit of pneumococcal vaccination across CRD subtypes.^1,3

In the pivotal Community-Acquired Pneumonia Immunization Trial in Adults (CAPITA), which enrolled more than 84,000 adults aged 65 years and older, 13-valent pneumococcal conjugate vaccine (PCV13) demonstrated 45.6% efficacy (95% CI, 21.8%-62.5%) against vaccine-type CAP and 75% efficacy (95% CI, 41.4%-90.8%) against vaccine-type invasive pneumococcal disease.³

In patients with COPD specifically, a Cochrane review of 12 randomized controlled trials—9 of which used the 23-valent pneumococcal polysaccharide vaccine (PPV23, also referred to as PPSV23)—found that pneumococcal vaccination reduced acute exacerbation and hospitalization risk, with efficacy against community-acquired pneumonia reaching 76% among patients 65 years and older in one included trial.¹

In patients with asthma, both steroid-dependent and steroid-independent cohorts developed elevated serotype-specific antibody levels 4 weeks after PPV23 administration, and vaccinated patients experienced a reduced risk of hospitalization attributable to pneumococcal infection.¹

A Chinese cohort study of patients with bronchiectasis found a significantly lower rate of recurrent pulmonary infection over 1 year among those who received PPV23 compared with unvaccinated controls (17.85% vs 45.70%).¹

Among patients with lung cancer who received PPV23 within 6 months of starting antitumor therapy, CAP incidence fell by 26%, 2-year CAP hospitalization rates were lower (37.1% vs 55.4%), and overall survival improved (46.6% vs 26.2%) compared with unvaccinated patients.¹

Safety data across these populations were reassuring. Adverse events following pneumococcal vaccination were generally mild and self-limiting, most commonly localized injection-site pain or swelling, with systemic reactions such as fever, myalgia, or chills occurring less frequently. Serious events were rare. Febrile seizures occurred in fewer than 2 per 10,000 doses following PCV13, and anaphylaxis occurred in fewer than 1 per 1,000,000 doses following PPV23.¹

Coadministration of pneumococcal and influenza vaccines at separate injection sites during the same visit produced comparable immunogenicity to separate-visit administration and was associated with reduced outpatient visits, hospitalization rates, and length of stay in elderly patients with chronic conditions, without a significant increase in adverse events.¹

Vaccination Rates Remain Below Recommendations

Despite this evidence, vaccination coverage in CRD populations remains inconsistent worldwide. The consensus reports that pneumococcal vaccination rates among the elderly in China range from just 1.8% to 42.1%, compared with 67.5% in the United States and 70.6% in the United Kingdom. Among elderly patients with COPD in China specifically, the pneumococcal vaccination rate was only 1.2%. Cited reasons for low uptake include inadequate patient awareness, skepticism about vaccine efficacy, cost and safety concerns, limited recommendations from medical personnel, and poor access to vaccination services.¹

Coverage disparities are not limited to China. A review of pneumococcal vaccination in chronic respiratory disease found recent coverage rates of 70% among adults 65 years and older in the United Kingdom and 76% among adults 60 years and older in Spain, but only 36% among adults 65 years and older in Ireland (18% in high-risk adults), 15% to 30% in Norway, 15% in high-risk adults in Germany, and approximately -5% in adults 65 years and older in France between 2010 and 2011.³

A separate survey found that although 85% of adults 50 years and older trusted vaccines generally, 55% of unvaccinated respondents said pneumococcal vaccination had never been offered by their physician—underscoring the role clinicians and pharmacists play as the primary source of vaccine information for this population.³

Current Guidance and the Pharmacist's Role

Recommendations for pneumococcal vaccination in CRD populations are broadly aligned across major guideline bodies, though specific product recommendations vary by country and by the vaccines each health system has approved. The Advisory Committee on Immunization Practices (ACIP) recommends that all adults aged 65 years and older receive either a single dose of 20-valent pneumococcal conjugate vaccine (PCV20) alone or co-vaccination with 15-valent pneumococcal conjugate vaccine (PCV15) followed by PPV23. Canada's National Advisory Committee on Immunization recommends PCV20 for adults 50 years and older at high risk of pneumococcal infection and for all adults 65 years and older, with sequential PCV15-then-PPV23 as an alternative if PCV20 is unavailable.¹

The 2024 Global Initiative for Chronic Obstructive Lung Disease guidelines recommend either a single dose of PCV20 or sequential administration of PCV15 and PPV23 for patients with COPD. The 2023 Global Initiative for Asthma guidelines note insufficient evidence to recommend routine pneumococcal vaccination in all patients with asthma, though the CDC recommends PPV23 for adults with asthma; the British Thoracic Society recommends pneumococcal vaccination for all patients with bronchiectasis; and the 2023 National Comprehensive Cancer Network guidelines recommend pneumococcal vaccination at an appropriate clinical timepoint for patients with lung cancer.¹

Current CDC guidance reflects this same risk-based approach. Chronic lung disease—defined by the CDC to include COPD, emphysema, and asthma—qualifies as an adult risk indication for pneumococcal vaccination.²

For adults aged 19 to 49 years with chronic lung disease who have never been vaccinated, the CDC recommends a single dose of PCV15, PCV20, or 21-valent pneumococcal conjugate vaccine (PCV21), with PPV23 to follow at least 1 year later only if PCV15 was used. PCV20 and PCV21 require no additional doses to complete the series. Patients who previously received only PPV23 should receive a single dose of PCV15, PCV20, or PCV21 at least 1 year later, and those who previously received only PCV13 should receive PCV20 or PCV21 at least 1 year later. The CDC offers PneumoRecs VaxAdvisor, a free tool available for iOS, Android, and web browsers, to help clinicians and pharmacists navigate patient-specific vaccination histories.²

Pharmacists working with US patients should note an important distinction. The newly published consensus is calibrated to China's current vaccine landscape, where only PCV13 and PPV23 are approved and where PCV15 and PCV20 are not yet available for adult use—meaning the consensus recommends PPV23 alone for elderly patients with CRD who have not previously been vaccinated.¹

US guidance, by contrast, is built around the broader menu of PCV15, PCV20, and PCV21 now available domestically.² The clinical message that pharmacists can act on immediately, however, is consistent across both bodies of evidence. Patients with COPD, asthma, bronchiectasis, or lung cancer belong in a high-risk category for pneumococcal disease. Vaccination in this population is both immunogenic and well tolerated, and closing the awareness and access gaps identified in this research is likely to fall, in large part, to the pharmacists and other clinicians these patients see most often.

REFERENCES

1. Wang L, Yu Q, Chen Q, Yu P; Expert Committee of Consensus Opinion on Influenza Vaccine and Pneumococcal Vaccine Vaccination for Elderly People with Chronic Respiratory Diseases, Respiratory Group of Chinese Geriatrics Society. Expert consensus on influenza vaccine and pneumococcal vaccination in elderly people with chronic respiratory diseases (2024). Aging Medicine. 2026;0:1-12. doi:10.1002/agm2.70090

2. Centers for Disease Control and Prevention. Pneumococcal vaccination: risk-based recommendations for adults. CDC website. Updated May 8, 2026. Accessed August 17, 2026. https://www.cdc.gov/pneumococcal/hcp/vaccine-recommendations/risk-indications.html

3. Froes F, Roche N, Blasi F. Pneumococcal vaccination and chronic respiratory diseases. Int J Chron Obstruct Pulmon Dis. 2017;12:3457-3468. doi:10.2147/COPD.S140378