Since 2000, when the first pneumococcal conjugate vaccine was introduced into routine use in the USA, it has had a substantial impact on invasive pneumococcal disease both in the immunized and nonimmunized population. It has also been shown to reduce pneumonia and otitis in young children and has reduced antibiotic nonsusceptible pneumococcal infections. In the USA, three primary doses and a booster dose are recommended (a so-called '3 + 1 schedule'). Some countries have or will soon introduce routine immunization with fewer doses, with either two primary doses and a booster dose ('2 + 1 schedule') or no booster dose ('3 + 0 schedule'). Some serotypes produce less antibody in a two-dose compared with a three-dose primary series. The booster dose may also be important in reducing nasopharyngeal carriage, hence absence of a booster dose may reduce indirect protection. It remains to be seen whether these schedule changes will reduce vaccine effectiveness within the population. Important future developments include extending the number of serotypes included in the vaccine and the possible extension of use into adults in whom indirect protection has been useful, but not as extensive as might be possible with direct immunization.