9. I have an autoimmune disease – should I get a booster dose?
The CDC recently adjusted their language around COVID-19 vaccines, and recommendations now include staying up to date with COVID-19 vaccines for adequate protection. That being said, there are separate recommendations for those who are immunocompromised. “For people who are immunocompromised, the third primary dose is the final dose of the primary series of an mRNA COVID-19 vaccine. Boosters are shots that enhance or restore protection against COVID-19, which may have decreased over time” (5).
Generally, living with an autoimmune disease does not necessarily mean you are immunocompromised. Oftentimes, certain medications and treatments may cause immunosuppression while reducing an autoimmune reaction. A consensus has not been made on the antibody threshold for adequate immunity against SARS-CoV-2. For this reason, it is recommended that you speak with your doctor about staying up to date with COVID-19 vaccines.
This page details the COVID-19 immunization schedule per the CDC (accurate as of September 9, 2022).
On April 19, 2023, the CDC issued a blanket recommendation that everyone ages 6 years and older receive an updated bivalent mRNA COVID-19 vaccine, regardless of whether they were fully vaccinated with the monovalent primary series. Regarding immunocompromised persons, new recommendations allow for an additional bivalent vaccine dose. “This allows more flexibility for healthcare providers to administer additional doses to immunocompromised patients as needed.”
On October 3, 2022, the FDA published updated information on Evusheld, citing data that shows a 1,000 fold decrease in efficacy as a prophylaxis against the omicron subvariant.
On September 14, 2022, the CDC published their recommendation on the bivalent booster for those who are moderately to severely immunocompromised; they also cover eligibility for Evusheld.
On September 1, 2022, the CDC updated their recommendation for those 18+ to receive a Pfizer or Moderna bivalent booster. The updated booster targets the most recent Omicron subvariants, as well as the original SARS-CoV-2 strain.
On March 29, 2022, the CDC updated their recommendation to include a second booster dose for immunocompromised persons using the Pfizer or Moderna vaccine.
On January 7, 2022, the CDC updated their vaccine guidance for immunocompromised persons. It is now recommended that persons 12+ who are immunocompromised receive a booster dose. “If you are eligible for an additional primary shot, you should get this done before you get a booster shot.”
On December 16, 2021, the CDC recommended against the use of a second J&J dose following a J&J primary dose. Thrombosis with thrombocytopenia has been verified by the FDA and CDC as a rare but possible adverse event after receiving the J&J vaccine; given their recommendation on boosters in light of the Omicron variant, the CDC’s official stance now recommends an mRNA vaccine booster after the initial J&J primary dose. That being said, those wanting to receive two doses of a J&J vaccine may do so; it is recommended that you speak with your doctor beforehand.
On November 29, 2021, the CDC changed their recommendation on boosters in an effort to combat the Omicron variant. Adults “should” receive a booster, rather than “may” receive a booster 6 months after their Pfizer or Moderna primary series, or 2 months following their initial J&J vaccine.
On November 19, 2021, the CDC expanded booster eligibility for everyone over 18 years of age. Those who received a Pfizer or Moderna vaccine may receive a booster dose 6 months after their primary series.
Ahead of the CDC’s endorsement, an advisory committee to the CDC convened to discuss two new recommendations. Members voted 11-0 in favor of both recommendations:
#1 – A single COVID-19 vaccine booster dose is recommended for persons aged 18+ who received an mRNA COVID-19 vaccine primary series based on individual benefit and risk, at least 6 months after the primary series, under the FDA’s emergency use authorization.
#2 – A single COVID-19 vaccine booster dose is recommended for persons 50+ years who received an mRNA COVID-19 vaccine at least 6 months after the primary series under the FDA’s emergency use authorization.
On October 26, 2021, the CDC updated their guidelines on COVID-19 vaccines for those who are “moderately and severely” immunocompromised. Those who received an mRNA vaccine for their primary series and received an additional dose of an mRNA vaccine, may receive a fourth COVID-19 booster dose at 6+ months. This fourth dose may be administered using a Moderna, Pfizer or Johnson & Johnson (J&J) vaccine. “In such situations, people who are moderately and severely immunocompromised may receive a total of four COVID-19 vaccine doses.”
If obtaining the Moderna vaccine for a third dose, one should receive a 50 microgram dose, followed by a fourth 50 microgram dose at 6+ months.
Those who are immunocompromised and received the J&J vaccine for their primary series should get a second COVID-19 vaccine. If the J&J primary dose is followed by a Moderna booster, it should measure 50 micrograms. Those who received a J&J vaccine for their primary series followed by either a second dose of the J&J, Moderna or Pfizer vaccine should not obtain a third dose at this time. Speak with your doctor regarding the timing of a fourth dose, as they are “best positioned to determine the appropriate timing of vaccination.”
On October 21, 2021, the CDC amended their EUA to include a booster recommendation for the Moderna and Johnson & Johnson vaccines.
The Moderna vaccine has been endorsed for use as a booster vaccine at least 6 months after the primary series in the following populations:
- those 65+ years in age
- those 18+ in long-term care settings
- those 18+ who have certain underlying medical conditions
- those 18+ who work or live in high-risk settings
The Johnson & Johnson (J&J) vaccine has been recommended for persons 18+ years of age, 2 months after their primary dose.
The CDC also endorsed a mix-and-match strategy for booster doses. Unlike the Moderna booster (which is a half dose at 50 micrograms), Pfizer and J&J booster doses will measure the same as the primary series. The ACIP, the advisory panel to the CDC, recommended that those who are immunocompromised and completing a primary series as well as an additional dose, should utilize vaccines from the same manufacturer. Those who are “moderately to severely” immunocompromised and received a J&J primary series, should receive a 50 microgram dose of the Moderna vaccine should they decide to mix-and-match between their first and second dose. Those who receive a third, 100 microgram dose of the Moderna vaccine due to their immunocompromised status, should not get a 4th booster shot from Pfizer or J&J at this time (1).
On September 24, 2021, the CDC updated their recommendations for a booster dose of the Pfizer vaccine at least 6 months after a primary series for the following individuals:
- people 65 years and older and residents in long-term care settings
- people aged 50–64 years with underlying medical conditions people aged 18–49 years with underlying medical conditions may receive a booster shot based on their individual benefits and risks, and
- people aged 18-64 years who are at increased risk for COVID-19 exposure and transmission because of occupational or institutional setting may receive a booster shot based on their individual benefits and risks.
On August 12, 2021, the FDA authorized the use of an additional dose of Pfizer-BioNTech and Moderna’s COVID-19 vaccines for those who are immunocompromised and may not have developed sufficient antibodies after a full dose of the COVID-19 vaccine. These patients include those who have received solid organ transplants, as well as “those who are diagnosed with conditions that are considered to have an equivalent level of immunocompromise.”
On August 13, 2021, the FDA authorized the use of a third dose of the Moderna vaccine as well, which measures 100 micrograms. This is the same dose as the first two of the primary series.
The NIH is currently holding a clinical trial on Booster Vaccine in Autoimmune Disease Non-Responders. This study will determine the antibody response of a booster dose in autoimmune disease patients who did not respond to an initial full dose of the COVID-19 vaccine. The trial includes participants living with one of five autoimmune diseases: rheumatoid arthritis, pemphigus, systemic lupus erythematosus, systemic sclerosis, or multiple sclerosis, and taking mycophenolate mofetil (MMF) or mycophenolic acid (MPA), methotrexate (MTX), or B cell-depleting drugs. These immunosuppressive therapies have been associated with low antibody production after the COVID-19 vaccine.