Patients who are immunocompromised are advised to get a three-dose series and then a fourth dose.
The CDC’s Advisory Committee on Immunization Practices (ACIP) met February 4, 2022, to provide further guidance for immunocompromised patients and address obstacles this population has encountered in getting an additional COVID-19 dose. The revised recommendations say thatpatients who are moderately or severely immunocompromised should receive a fourth dose of an mRNA vaccine at least three months after the last dose of a three-dose series.
The CDC has previously recommended that immunocompromised patients who received the mRNA Pfizer-BioNTech (Comirnaty) or Moderna (Spikevax) vaccines get a fourth shot at least five months after their third vaccination. However, these recommendations may have been lost in the shuffle. CNN reported that some pharmacies have turned away immunocompromised patients seeking a fourth shot. Pharmacies turning away patients could be the result of unclear messaging or confusion regarding the guidance.
“There has been recent confusion about the recommendations for this population, including reports of people who choose mRNA COVID-19 vaccines being denied their fourth dose,” said Elisha Hall, Ph.D., CDC health education specialist, at the ACIP presentation according to CNN’s coverage. The presentation emphasized that individuals with immunocompromising health conditions (e.g., active cancer and organ transplant recipients) and patients who take immunosuppressive medications are at increased risk of severe COVID-19 and may not have a strong enough protective immune response after initial vaccination. Additionally, this population can experience waning vaccine protection over time.
The updated recommendations are based on evidence demonstrating that patients who are immunocompromised have a stronger immune response when a fourth dose is administered one to three months after the third dose. The guidance further clarifies the recommendation language that immunocompromised patients should receive a three-dose primary series, with a fourth dose considered the booster. For people who are not in the immunocompromised category, the recommended sequences remains a two-dose primary series followed by a booster.
Pharmacies should ensure they are following CDC recommendations to ensure immunocompromised patients are current on their COVID-19 vaccine series.
These recommendations apply to immunocompromised patients, ages 12 years and older, who have received the Pfizer-BioNTech vaccine and those 18 year and older who have received the Moderna vaccine.
Under the revised guidance, ACIP is also recommending that immunocompromised patients who received one primary dose of the Johnson & Johnson vaccine also get an additional dose of an mRNA vaccine at least 28 days later followed by an mRNA booster vaccine — a third dose — at least two months after second shot.
Due to the risk of thrombosis with the Johnson & Johnson vaccine, the CDC recently recommended an mRNA as the preferred COVID-19 vaccine.
Under what is known as Emergency Use Instructions (EUI), the CDC has the authority to make these guideline revisions independently once a product has been approved. They may differ from the FDA prescribing information.
ACIP has also recommended that healthcare providers can, on a case-by-case basis, administer additional doses of the Pfizer-BioNTech or Moderna vaccines outside of the FDA and CDC dosing intervals “based on clinical judgement when the benefits of vaccination are deemed to outweigh the potential and unknown risks.”