This survey describes patterns of pneumococcal polysaccharide vaccine use, vaccine registration, vaccination recommendations, and reimbursement for vaccination in the United States and 20 other developed countries during the period 1981 through 1996. The United States was the only country to use appreciable amounts of the vaccine throughout the study period. Annual vaccine use was staple from 1982 through 1990 but then increased sharply. In the 20 other countries, very little pneumococcal vaccine was used until the 1990s, when new registrations and/or national recommendations were followed by dramatic increases in vaccine use in Iceland (1991), the United Kingdom (1994), Sweden (1995), and Norway, Belgium, and the province of Ontario in Canada (1996). In 1996, pneumococcal vaccine was still not licensed in three and not recommended in four of the 21 countries. Of the seven countries that used the most pneumococcal vaccine, public reimbursement for vaccination was provided in the United States, Canada, and the United Kingdom but not in Iceland, Sweden, Norway, or Belgium.