Fourth Shot is Recommended for the Immunocompromised

MHE Publication, MHE March 2022, Volume 32, Issue 3

Getting boosted is now the rule, not the exception, when it comes to COVID-19 vaccination recommendations. The CDC now recommends that everyone, ages 12 and older, get a dose of an mRNA COVID-19 vaccine, either Pfizer’s or Moderna’s. For people who have gotten the two-shot Pfizer or Moderna series, the booster is their third jab. For those who got the single-dose Johnson & Johnson vaccine, it is the second.

Getting boosted is now the rule, not the exception, when it comes to COVID-19 vaccination recommendations. The CDC now recommends that everyone, ages 12 and older, get a dose of an mRNA COVID-19 vaccine, either Pfizer’s or Moderna’s. For people who have gotten the two-shot Pfizer or Moderna series, the booster is their third jab. For those who got the single-dose Johnson & Johnson vaccine, it is the second.

But for people who are immunocompromised — people in active cancer treatment, for example — to be fully boosted means a fourth dose. Early last month, the CDC’s Advisory Committee on Immunization Practices recommended that people who are immunocompromised get a fourth dose of vaccine at least three months after the last dose of a three-dose series of shots. The CDC is calling the third shot for people who immunocompromised a third primary shot, not a booster. It doesn’t recommend the Johnson & Johnson vaccines for those who are immunocompromised.

The CDC says that about 2.7% of the adult population in the U.S. are immunocompromised. People who are immunocompromised are more likely to experience a severe case of COVID-19 and also a prolonged one.

A number of news outlets have reported that some pharmacies have turned away immunocompromised patients seeking a fourth shot, even though it is recommended by the CDC. Under what is known as emergency use instructions the CDC has the authority to make these guideline revisions, independent of the FDA once a product has been approved.

The updated recommendations are based on evidence that people who are immunocompromised have a stronger immune response when a fourth dose is administered one to three months after the third dose. The most recent guidance clarifies that immunocompromised patients should receive a three-dose primary series, with a fourth dose considered the booster.

For people who are not immunocompromised, the recommended sequence remains a primary series comprising two doses followed by a third, the booster.

The CDC’s Advisory Committee on Immunization Practices has also recommended that healthcare providers can, on a case-by-case basis, administer additional doses of the Pfizer 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.”