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cdc.gov/coronavirus
COVID -19 Vaccine :
Considerations for Future Planning
Sara Oliver, MD, MSPH
ACIP MeetingFebruary 24, 202 3
Considerations for future planning
COVID -19 vaccines
COVID -19 vaccines:
Where we are now How do we
get there?COVID -19 vaccines:
Where we are going
Considerations for future planning
COVID -19 vaccines
COVID -19 vaccines:
Where we are now How do we
get there?COVID -19 vaccines:
Where we are going
Considerations for future planning
COVID -19 vaccines
COVID -19 vaccines:
Where we are now COVID -19 vaccines:
Where we are going Where we are now :
Current recommendations
Vaccination rates
Hospitalization rates
How we get there :
How frequently should people get a COVID -19 vaccine?
Are there groups/populations who should have >1 vaccine per year? Goal :
Simple
recommendations
Current recommendations
https://www.cdc.gov/vaccines/covid -19/images/COVID19- vaccination -schedule -most -people.png
https://www.cdc.gov/vaccines/covid -19/images/COVID19- vaccination -schedule -immunocompromised.png
Coverage / Age (years) <2 2–4 5–11 12–17 18–24 24–49 50–64 >65
At least 1- dose† 7.6 10.3 39.7 71.9 81.9 85.2 95.0 95.0
Completed primary series 3.7 5.5 32.6 61.6 66.5 72.0 83.7 94.2
1st monovalent booster* - - 3.3 16.6 27.2 45.3 64.6
2nd monovalent booster * - - - - - - 10.6 25.3
Bivalent booster** 0.2 0.3 4.0 7.0 6.7 11.2 20.3 40.8
Unvaccinated 92.4 89.7 60.3 28.1 18.1 14.8 —†—†U.S. COVID-19 Vaccination Coverage (%) of Total Population by
Age Group — February 8, 2023
*Monovalent booster dose coverage as of August 26, 2022
** Bivalent booster coverage is independent of 1stand 2nddose monovalent coverage
†Note: Coverage is capped at 95%
Source: https://covid.cdc.gov/covid -data -tracker/#vaccination -demographics -trends Updated February 10, 2023 6
U.S. COVID-19 vaccine uptake by age group,
August 2021 -January 2023
Source: IZ Data Lake 01,000,0002,000,0003,000,0004,000,0005,000,0006,000,0007,000,000
Primary Series, Ages 12-17 Primary Series, Adults Ages 18-49 Primary Series, Adults Ages 50-64 Primary Series, Adults Ages 65+
Booster, Ages 12-17 Booster, Adults Ages 18-49 Booster, Adults Ages 50-64 Booster Adults Ages 65+Primary series authorization
1stbooster authorization
2ndbooster authorization Bivalent booster authorization Doses Administered
COVID-19 message fatigue challenges vaccine uptake
Recent studies reflect profound COVID- 1 9 message fatigue1, desire to end use of
mitigation2, and a common perception among adults that immunity is
sufficient without further boosters3
Barriers to vaccine access persist for some populations, i ncluding but not limited to:
–
––People living in rural areas
4
People experiencing homelessness5
People with disabilities6
•"If I can't get to it, it doesn't exist for me."
Despite improvements in vaccine equity after primary series vaccination, disparities i
n booster coverage have emerged7
1. Guan et al. Health Communication 2022: COVID -19 Message Fatigue: How Does It Predict Preventive Behavioral Intentions and What Types of Information are People Tired of
Hearing About? -PubMed (nih.gov) 2. CDC's State of Vaccine Confidence Insights Reports, Jan 26 2023: CDC’s State of Vaccine Confidence Insights Report 3. Sinclair et al. MMWR Jan
20 2023: MMWR, Reasons for Receiving or Not Receiving Bivalent COVID -19 Booster Vaccinations Among Adults —United States, November 1 –Dec ember 10, 2022 (cdc.gov)
4.Assessing barriers to access and equity for COVID -19 vaccination in the US -PMC (nih.gov) 5. McCosker et al. Vaccine May 2022: Strategies to improve vaccination rates in people
who are homeless. 6. Griffin -Blake et al. Barriers and facilitators of COVID -19 vaccine uptake among people with disabilities. P resentation to the COVID -19 Vaccine Innovation Team:
Feb 8 2023. 7. COVID -19 Vaccination Coverage, by Race and Ethnicity —National Immunization Survey Adult COVID Module, United States, December 2020– November 2021 |
MMWR (cdc.gov)
PI=Prediction Interval, VOC=Variants of Concern, VBM=Variants Being Monitored . https://covid.cdc.gov/covid -data- tracker/#variant -proportions Accessed Jan 20, 2023Trends in weighted variant proportion estimates & Nowcast
United States, November 6, 2022 –February 11, 2023
Collection date, week ending
Estimated Number of Reported COVID -19 Cases by Variant
Variant Proportions Scaled by Positive Nucleic Acid Amplification Test (NAAT) Counts
CDC COVID- 19 Lab Coordinating Unit Strain Surveillance and Emerging Variant Group. Data sources: https://covid.cdc.gov/covid- data-tracker/#variant -proportions and
https://covid.cdc.gov/covid- data-tracker/#trends_newtestresultsreported_7daytestingpositive_00
6M
04M
2MPositive tests / Proportion of viral lineages
Seroprevalenc e by Vaccine and Infection H istory Among
Adult U.S. Blood Donors, January –June 2022
Q1 = Jan.–Mar. 2022
Q2 = Apr.–Jun. 202243
35 35
254438615668 6730
3733
433136182417 2020 2225 2818 21 9 108 98 6 7 47 5
12 106 4
0%10%20%30%40%50%60%70%80%90%100%
Q1 Q2 Q1 Q2 Q1 Q2 Q1 Q2 Q1 Q2
Overall 18 to 49 50 to 64 65 to 74 75 and overSeroprevalence
Age (years) and quarterNo immunity
Infection only induced
immunity
Both vaccine and infectioninduced immunity
Vaccine only inducedimmunity
Source: https://covid.cdc.gov/covid- data-tracker/#nationwide -blood- donor -seroprevalence- 2022
Weekly population-based rates of COVID-19 -associated hospitalizations
by age group— COVID -NET, March 2020 –February 2023
Gray boxes indicate potential reporting delays. Interpretation of trends should be excluded from these weeks.
Age Group
Monthly Age-Adjusted Rates of Lab- Confirmed Hospitalizations by Vaccination Status
among Adults Ages ≥18 Years —COVID- NET, January 2021–December 2022
0100200300400500600700Rate per 100,000 population
Month of Admission
Unvaccinated Primary series Primary series & ≥1 booster Primary series & ≥2 boosters Vaccinated, no bivalent booster Updated bivalent booster
Data are based on all hospitalizations regardless of reason for admission. Unvaccinated : No recorded doses of COVID -19 vaccine. Primary series ± ≥1 booster: Completed a primary series with or without ≥1
booster dose but did not receive an updated bivalent booster dose. Vaccinated, but no bivalent booster: Completed a primary series with or without ≥1 booster dose but did not receive an updated bivalent
booster dose. Updated bivalent booster : Received updated bivalent booster dose. Persons with partial or unknown vaccination status are excluded. See https://covid.cdc.gov/covid-data-tracker/#covidnet -
hospitalizations-vaccination for complete definitions of vaccination categories. In December 2022, compared to adults who
received an updated bivalent booster dose,
the monthly rates of hospitalization were
-16x higher among unvaccinated and
-2.6x higher in vaccinated adults without an updated booster dose
COVID- 19 vaccine
Where we are now
Current COVID- 19 vaccine recommendations are complex
Uptake of current bivalent vaccine is low
SARS -CoV-2 continues to evolve, but recent virus evolution has not led to large
population- level surges in cases or hospitalizations
Most adults have a prior infection, prior vaccination, or both
Hospitalization rates are highest older adults , but remain low among people who
have received a bivalent booster
Considerations for future planning
COVID -19 vaccines
COVID -19 vaccines:
Where we are now COVID -19 vaccines:
Where we are going
How we get there :
How frequently should people get a COVID -19 vaccine?
Are there groups/populations who should have >1 vaccine per year? Goal :
Simple
recommendations
How frequently should people get a COVID-19 vaccine?
Increases in COVID-19 cases (left) and hospitalizations (right) have occurred:
–During the winter months a nd/or
–Due to development of new i mmune escape variant
Cases from October 2021- February 2023 highlighted
https://covid.cdc.gov/covid -data-tracker/#trends_weeklycases_select_00 https://covid.cdc.gov/covid -data -tracker/#new -hospital -admissionsAdmissions from October 2021 – February 2023 highlighted
How frequently should people get a COVID-19 vaccine?
With monovalent COVID- 19 vaccines,
declines in VE noted over time
Likely impacted by both time since
vaccine dose and continued virus
evolution
Additional vaccine doses restored
protection lost over time
Continue to monitor impact of waning and virus evolution on VE for bivalent vaccines
VE = vaccine effectiveness
BA.2/BA.2.12.1 estimates: Link -Gelles et al. MMWR : https://www.cdc.gov/mmwr/volumes/71/wr/mm7129e1.htm
BA.4/BA.5 estimates: Link -Gelles et al. medRxiv : https://www.medrxiv.org/content/10.1101/2022.10.04.22280459v1 . Individuals with prior infections excluded. Adjusted for calendar time,
geographic region, age, sex, race, ethnicity, local virus circulation, respiratory or non -respiratory underlying medical conditi ons, and propensity to be vaccinated.
How frequently should people get a COVID-19 vaccine?
VE = vaccine effectiveness
CDC unpublished data. Updated from: Tenforde et al. MMWR December 16, 2022: https://www.cdc.gov/mmwr/volumes/71/wr/mm715152e1.htmTime since last dose impacts COVID- 19 vaccine effectiveness
–Relative VE of bivalent boosters (meaning the additional benefits of a bivalent booster) are higher
the longer it has been since the last monovalent dose
Safety is also likely improved with longer time between doses
–Myocarditis risk appears lower with longer time between doses
VISION: VE of bivalent
COVID -19 boosters against
hospitalizations among
adults aged ≥18 years –
VISION Network,
September –December 2022
How frequently should people get a COVID-19 vaccine?
Summary
Winter months and immune escape variants have impacted COVID- 19 epidemiology
–This past winter did not see same level of increases in cases/hospitalizations as previous winters
Time since last COVID- 19 vaccine dose may both increase the incremental benefits of a
COVID -19 vaccine, and decrease the risk of myocarditis
Vaccine protection likely declines over time
A plan for a fall booster dose could provide added protection, at a time when many
would be ~1 year from last dose
–Future epidemiology and SARS- CoV-2 virus evolution could help determine the need for
continued annual boosters
Are there populations who still need a primary series ?
Unvaccinated young children
While most adults have completed a primary series, most children ages 6 months –4 years
remain unvaccinated
For most older children, adolescents, and adults, future doses will be additional ‘boost’
a
fter prior infection, prior vaccination, or both
Young children will continue to age into the vaccine recommendations at 6 months and c
ould be SARS -CoV-2 naive
Some population of y oung children likely still need a ‘prime’ and ‘boost’ to optimize
immunity
Coverage / Age (years) <2 years 2–4 years
At least 1 -dose 7.6 10.3
Completed primary series 3.7 5.5
Unvaccinated 92.4 89.7
For parents with an unvaccinated or under -vaccinated child aged 6 –23 months, 38%
intend to get their child vaccinated in the next month, whereas 39.4% say they
‘definitely’ or ‘probably’ will not vaccinate their child and 23% are unsure
Additionally, 38% of parents of children ages 2 –4 years say they ‘definitely’ or
‘probably’ will get their child vaccinated in the next month, while 43.2% say they
‘definitely’ or ‘probably’ will not and 18.4% are unsure
Doctor’s offices and clinics were the most trusted place for parents to have their child
receive a COVID- 19 vaccine, as reported by 51.1% of parents of children aged 6 –23
months and 52.5% of parents of children aged 2 –4 yearsParental intent to get a COVID-19 vaccine for their child and
trusted places for children to receive a COVID-19 vaccine
CDC/University of Iowa/RAND survey. Unpublished data.
Gray boxes indicate potential reporting delays. Interpretation of trends should be excluded from these weeks. Are there populations who still need a primary series ?
Unvaccinated young children
0510152025Rate per 100,000 population
Week Ending Date
6 months –<2 years 2–4 yearsPediatric hospitalization rates are higher among children 6 months to <2 years of a ge,
compared to children 2 –4 years of age
Weekly Population -Based Rates of COVID-19-Associated Hospitalizations among Children Ages 6 months -4 Years
—COVID -NET, March 2020– February 2023
63828993
0102030405060708090100
Mar-Apr May-Jun Jul-Aug Sep-Oct Nov-DecSeroprevalence (%)
Month7585929799
0102030405060708090100
Mar-Apr May-Jun Jul-Aug Sep-Oct Nov-DecSeroprevalence (%)
MonthPediatric SARS -CoV- 2 Infection- Induced and Combined (Vaccine -and Infection-
Induced) Seroprevalence from U.S. Commercial Laboratories —
March –December 2022
Source: https://covid.cdc.gov/covid- data-tracker/#pediatric -seroprevalence and unpublished data from CDCInfection -induced Combined
(vaccine- and infection -induced)
Are there populations who still need a primary series ?
Summary
Children ages <2 years have higher COVID- 1 9
hospitalization rates than older children
Children ages <4 years are less likely to have both
pr
ior infection and prior vaccination
Children have frequent visits to healthcare providers
The Work Group discussed continued primary series r
ecommendations for young children
Both ages 6 months- 2 years and ages 6 months-4
years were discussed without a clear consensus
https://www.healthychildren.org/English/family -life/health -management/Pages/Well- Child -Care-A- Check -Up-for-Success.aspx
Should older adults be recommended for >1 vaccine annually?
Hospitalization
r
ates are highest
among adults 65–74 years and
≥75 years of age
Age-Adjusted Rates of COVID -19-Associated Hospitalization by Vaccination Status and
Receipt of Booster Dose in Adults Ages ≥65 Years
COVID -NET, January 2021 –December 2022
CDC COVID Data Tracker. https://covid.cdc.gov/covid -data -tracker/#covidnet -hospitalizations -vaccination Accessed Feb 17, 2023In December 2022, adults ages ≥65 years
who received a bivalent booster had
12.8X lower risk of hospitalization for
COVID- 19 compared to unvaccinated
people and 2.5X lower risk of
hospitalization compared to those
vaccinated without a bivalent booster
Should older adults be recommended for >1 vaccine annually?
Immunity and vaccine
response is different in
older adults
Patterns of vaccine
effectiveness, including waning, may be different in older adults
Waning for bivalent VE against hospitalization, including among older adults, isn’t yet known
Unpublished CDC data. From ACIP presentation February 24, 2022ICATT: Relative VE of bivalent booster against symptomatic infection in
adults aged ≥ 18 years, December 1, 2022 –February 13, 2023
Should older adults be recommended for >1 vaccine annually?
Summary
Older adults have higher rates of hospitalization than younger adults
Rates of vaccination among older adults who have received a bivalent COVID- 19 v accine
booster dose remain low
The Work Group emphasized the importance of older adults being up to date on c urrent
recommendations, including receiving a bivalent booster
The Work Group discussed more frequent COVID- 19 vaccine doses for older adults, and
at this time felt the data were insufficient to determine a conclusion
Recommendations can be updated based on data in older adults including:
–Hospitalization rates of older adults who have received a bivalent booster
–Bivalent VE and patterns of waning for older adults
–SARS - CoV-2 virus evolution and possibility of future immune escape variants
Should people with immunocompromise be recommended for >1
vaccine annually?
Numerous studies have demonstrated that mRNA C OVID -19 vaccine effectiveness
among immunocompromised persons is lower than that of immunocompetent
persons, including within the period of Omicron predominance
This has been demonstrated across a range of immunocompromising conditions, and
i
s particularly notable for organ or stem cell transplant recipients
Among people with immunocompromise, recommendations prior to the bivalent boos
ter allowed for up to 5 monovalent doses of COVID-19 vaccine
Vaccine effectiveness studies are not yet sufficiently powered to evaluate e
ffectiveness of the bivalent booster among people with immunocompromise
Britton A, Embi PJ, Levy ME, et al. Effectiveness of COVID -19 mRNA Vaccines Against COVID -19– Associated Hospitalizations Among Immunocompromise d Adults During SARS -CoV-2 Omicron Predominance —VISION Network, 10 States,
December 2021 —August 2022. MMWR Morb Mortal Wkly Rep 2022;71:1335 –1342.
Embi PJ, Levy ME, and Patel P, et al. Effectiveness of COVID- 19 Vaccines at Preventing Emergency Department or Urgent Care Encounter s and Hospitalizations Among Immunocompromised Adults: an Observational Study of Real -World Data Across
10 US States from August—December 2021. Preprint. *Effectiveness of COVID-19 Vaccines at Preventing Emergency Department or Urgent Care Encounters and Hospitalizations Among Immunocompromised Adults: An Observational Study of Real -
World Data Across 10 US States from August- December 2021 (medrxiv.org)
Ferdinands J M, Rao S, Dixon B E, Mitchell P K, DeSilva M B, Irving S Aetal.Waning of vaccine effectiveness against moderate and severe covid -19among adults in the US from the VISION network: test negative, case -control study BMJ 2022; 379 :e072141 doi:10.1136/bmj -2022-
072141
Should people with immunocompromise be recommended for >1
vaccine annually?
VISION: mRNA COVID- 19 VE for
hospitalizations among immunocompetent
versus immunocompromised adults
during Omicron predominance
(mid- Dec. 2021—Jul. 2022)
Figure: Ferdinands J M, Rao S,Dixon B E, Mitchell P K, DeSilva M B, Irving S Aet al. Waning of
vaccine effectiveness against moderate and severe covid -19 among adults in the US from the
VISION network: test negative, case- control study BMJ 2022 30
VE among immunocompromised
per
sons is lower than that of
immunocompetent persons at comparable time points after dose 2 and dose 3
VE wanes in both immunocompetent a
nd immunocompromised persons
Should people with immunocompromise be recommended for >1
vaccine annually?
Summary
Immunocompromised adults can have less robust immune response to COVID- 1 9
vaccines
Not currently any authorized prophylactic monoclonal antibody products for populations
a
t highest risk of COVID- 19
The Work Group discussed more frequent COVID- 19 vaccine doses for people with
immunocompromise, and at this time felt the data were insufficient to determine a conclusion
The Work Group acknowledged this population may continue to be more vulnerable to s
evere COVID- 19 and likely needs flexibility with COVID- 19 vaccine recommendations
Considerations for future planning
COVID -19 vaccines
COVID -19 vaccines:
Where we are now COVID -19 vaccines:
Where we are going Goal :
Simple
recommendations
COVID -19 vaccines continue to be the most effective tool we have to prevent serious
illness, hospitalization and death from COVID -19
Goal of COVID- 19 vaccine program continues to be prevention of severe disease
–Prevention of post -COVID conditions, increased confidence in social interactions important
as well
Benefits of additional COVID- 19 vaccine booster doses vary by age, time since last
dose , and COVID- 19 incidence
A simplified, annual recommendation could help reduce vaccine and message fatigue
A COVID -19 vaccine framework that is similar to a well understood influenza vaccine
framework could be easy for COVID- 19 vaccine providers to implement, and for the
public to understand Considerations for future planning
COVID -19 vaccines
Simple recommendations are easier to communicate, which may improve uptake
–The Work Group was very supportive of simplified recommendations and planning for future
COVID -19 vaccines, which could include updated COVID -19 vaccines
Uncertainties remain for ideal timing and populations for future boosters, especially if new immune escape variants develop
The Work Group was supportive of a fall/annual COVID -19 vaccine program, with
flexibility to adjust based on new data, especially for populations at high risk
The Work Group will continue to review data to inform future deliberations:
–Vaccine effectiveness of bivalent COVID -19 vaccines over time
–Safety data of bivalent COVID-19 vaccines
–Cost effectiveness analyses
–COVID -19 epidemiology, including hospitalization rates among vaccinated and boosted persons
–SARS -CoV-2 genomic surveillance and virus evolution
–Data from vaccine manufacturers Work Group interpretation
Considerations for future planning
Monica Godfrey
Evelyn Twentyman
Danielle Moulia
Megan Wallace
Hannah Rosenblum
Lauren Roper
Katherine Fleming-Dutra
Ruth Link -Gelles
Amadea Britton
Sarah Meyer
Julianne Gee
Susan Goldstein
Mary Chamberland
Elisha HallValerie Morelli
JoEllen Wolicki
Heather Scobie
Sierra Scarbrough
Jefferson Jones
Aron Hall
Barbara Mahon
Data Analytics and Visualization Task Force
Coronavirus and other Respiratory Viruses Division
National Center for Immunization and Respiratory
DiseasesAcknowledgments
Question for ACIP
36Discussions about future COVID -19 vaccine recommendations are pre -decisional and
intended to inform planning and additional analyses.
What are ACIP's thoughts on a simplified framework for future COVID -19 vaccine
recommendations?
–What does ACIP think about children who may still need a primary series?
–What does ACIP think about future recommendations for older adults?
–What does ACIP think about future recommendations for people with
immunocompromising conditions ?
For more information, contact CDC
1-800- CDC- INFO (232- 4636)
TTY: 1 -888- 232- 6348 www.cdc.gov
The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.
Thank you