COVID-19 Booster Recommendations
All persons aged ≥5 years should receive a bivalent mRNA COVID-19 vaccine booster dose at least 2 months after completing their primary series or after receiving a monovalent booster dose to improve protection against COVID-19, particularly for those at increased risk for severe illness and death. 1
Current Booster Recommendations by Age Group
Children and Adolescents
- Children aged 6 months to 4 years: No booster dose is currently authorized 1
- Children aged 5 years: Pfizer-BioNTech bivalent booster recommended ≥2 months after primary series or monovalent booster 1
- Children aged 6-11 years: Either Moderna or Pfizer-BioNTech bivalent booster recommended ≥2 months after primary series or monovalent booster 1
- Adolescents aged 12-17 years: Either Moderna or Pfizer-BioNTech bivalent booster recommended ≥2 months after primary series or monovalent booster 1
Adults
- Adults aged ≥18 years: Either Moderna or Pfizer-BioNTech bivalent booster recommended ≥2 months after primary series or monovalent booster 1
- For adults who cannot or will not receive mRNA vaccines: Novavax monovalent booster may be used if they completed any FDA-approved or FDA-authorized primary series, have not received any booster doses, and are unable or unwilling to receive an mRNA vaccine 1
Special Considerations
Immunocompromised Individuals
- Moderately or severely immunocompromised persons should follow the same booster recommendations as the general population, but may have reduced protection 2
- Vaccine effectiveness for immunocompromised individuals is lower (28% vs 62% in non-immunocompromised) during the first 7-59 days after bivalent vaccination 2
- Immunocompromised individuals may benefit from additional protection with Evusheld (tixagevimab and cilgavimab) administered every 6 months to supplement vaccine-conferred protection 1
Timing Considerations
- Persons who recently had a SARS-CoV-2 infection may consider delaying a booster dose by 3 months from symptom onset or positive test result (if asymptomatic) 1
- Bivalent booster doses are authorized ≥2 months after the last primary series or monovalent booster dose 1
- The Novavax monovalent booster is authorized ≥6 months after the last primary series dose 1
Rationale for Bivalent Boosters
- Monovalent COVID-19 vaccines demonstrated decreased effectiveness during the Omicron variant predominance period 1
- Bivalent boosters contain equal amounts of spike mRNA from both the ancestral strain and Omicron BA.4/BA.5 strains to improve protection against current circulating variants 1
- Bivalent boosters provide additional protection against COVID-19-associated hospitalizations compared to monovalent vaccines alone 2
Durability of Protection
- Among non-immunocompromised adults, bivalent vaccine effectiveness against hospitalization is 62% during the first 7-59 days after vaccination, declining to 24% by 120-179 days 2
- Protection against critical outcomes (ICU admission or in-hospital death) remains higher and more sustained through at least 179 days 2
- By 6 months after boosting, protection against infection may wane significantly, but protection against severe outcomes remains substantial 3
Common Pitfalls and Barriers to Booster Uptake
- Low booster uptake: Only 18.5% of eligible adolescents and 27.1% of eligible adults had received a bivalent booster as of December 2022 4
- Lack of provider recommendation: 58.9% of adults open to receiving a booster reported not having received a provider recommendation 4
- Safety concerns: 16.9% of adults and 11.8% of parents of adolescents reported safety concerns about boosters 4
- Disparities in coverage: Lower booster coverage among rural residents and among Black and Hispanic populations compared to White populations 4
- Janssen (Johnson & Johnson) vaccine recipients: Should preferentially receive an mRNA booster due to risk of rare but serious adverse events (thrombosis with thrombocytopenia syndrome and Guillain-Barré syndrome) with additional Janssen doses 5
Effectiveness of Different Booster Strategies
- For Janssen primary series recipients: A heterologous mRNA booster (79% effective) provides higher protection than a homologous Janssen booster (54% effective) against COVID-19-associated emergency department/urgent care visits 5
- For mRNA primary series recipients: A third mRNA dose provides 90% effectiveness against COVID-19-associated hospitalizations during Omicron predominance 5
- All booster strategies provide higher protection than a single Janssen dose or primary series alone 5