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%%EOF Who can get a COVID-19 vaccine booster? Studies have shown that waiting a few months after an infection to get boosted can result in a stronger immune response from the shot, according to the CDC. Less than 60% of all Utahns are considered fully vaccinated, meaning it's been two weeks or more since completing their initial series of shots. For more information, see vaccine administration errors and deviations. Do not use the grace period to schedule doses. Studies also suggest that the antibodies produced after vaccination tend to remain at protective levels for longer. Nirmatrelvir is an oral protease inhibitor that is active against MPRO, a viral protease that plays an essential role in viral replication by cleaving the 2 viral polyproteins.1 It has demonstrated antiviral activity against all coronaviruses that are known to infect humans.2 Nirmatrelvir is packaged with ritonavir (as Paxlovid), a strong cytochrome P450 (CYP) 3A4 inhibitor and pharmacokinetic boosting agent that has been used to boost HIV protease inhibitors. The EUA advises against crushing nirmatrelvir and ritonavir tablets. Patients who undergo HCT or CAR-T-cell therapy should be revaccinated for the monovalent primary series andbivalentmRNA booster dose received before or during treatment. Renal impairment reduces the clearance of nirmatrelvir. Now, however, the agency's guidelines are based on three measures: new COVID-related . The patient is recommended to receive 1 bivalent mRNA booster dose at least 2 months after repeating the primary series. My patient who is moderately or severely immunocompromised underwent HCT or CAR-T cell therapy after receiving the primary series and 2 monovalent mRNA booster doses. Centers for Disease Control and Prevention. For primary series vaccination, Moderna, Pfizer-BioNTech, and Novavax COVID-19 vaccines are recommended. The CDC is also recommending that children between the ages of 5 and 11 that are moderately or severely immunocompromised should get a third dose of the COVID vaccine 28 days after their second . The Food and Drug Administration (FDA) issued an Emergency Use Authorization (EUA) for ritonavir-boosted nirmatrelvir on December 22, 2021, for the treatment of COVID-19.3. An overview of severe acute respiratory syndrome-coronavirus (SARS-CoV) 3CL protease inhibitors: peptidomimetics and small molecule chemotherapy. This reduction in body weight was not seen in the offspring of rats that had exposures that were 5 times higher than the clinical exposures at the authorized human dose.3. Does the 4-day grace period apply to COVID-19 vaccine? Available at: (CTC) BCTC, COVID Therapy Review and Advisory Working Group (CTRAWG). Oral nirmatrelvir for high-risk, nonhospitalized adults with COVID-19. Available at: Hammond J, Leister-Tebbe H, Gardner A, et al. Prescribing nirmatrelvir/ritonavir for COVID-19 in advanced CKD. Antibodies are an indicator of the bodys efforts to fight off the SARS-CoV-2 virus. Aligned with the U.S. Centers for Disease Control and Prevention (CDC) and the Federal Food and Drug Administration (FDA) to expand emergency use authorization (EUA) of Moderna and Pfizer-BioNTech bivalent vaccines for children 6 months and older. Yes. The booster helps people maintain strong protection from severe coronavirus disease. And of course, most experts agree that if its been more than five or six months since you got Covid-19 and you havent been boosted yet, you should do so as soon as youre eligible. FDA authorization allows for dosing options for certain other age transitions when a child ages from a younger to older age group. The following resources provide information on identifying and managing drug-drug interactions. Healthcare professionals should see Ending Isolation and Precautions for People with COVID-19. University of Liverpool. For more information, see considerations for COVID-19 revaccination. 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These cookies perform functions like remembering presentation options or choices and, in some cases, delivery of web content that based on self-identified area of interests. One of the reasons for this difference is that infections trigger many different parts of the immune system, and the size of the antibody response will depend on factors like how much virus you inhaled, whether you have underlying medical conditions and the severity of your symptoms. Booster doses may be heterologous. If you already had COVID-19 within the past 90 days, see specific testing recommendations. After revaccination with the primary series, the patient should receive 1 bivalent mRNA booster dose. If you are age 18 or older, and got the Janssen COVID-19 vaccine, you can get either of the mRNA vaccine bivalent boosters at least two months after your shot. And theres so much Omicron around right now that if you havent gotten it already, then this is a chance to avoid getting it., https://www.nytimes.com/2022/02/03/well/live/booster-after-covid.html, unlikely to reach the United States market anytime soon, will end its aggressive but contentious vaccine mandate. If possible, those quarantining should also stay away from the people they live with, particularly those who are . I was vaccinated in another country. Outside Canada and the USA: 1-604-681-4261. This will also allow for a more refined and durable response, he said. The new guidelines suggest that 90 percent of Americans can now stop wearing masks, according to TODAY. The most common adverse effects of ritonavir-boosted nirmatrelvir are dysgeusia, diarrhea, hypertension, and myalgia. For the Panels recommendations on preferred and alternative antiviral therapies for outpatients with COVID-19, see Therapeutic Management of Nonhospitalized Adults With COVID-19. Let your immune system rest after fighting off the coronavirus and before asking it to ramp up again with the vaccine. Should they be revaccinated? Tables with guidance on managing specific drug-drug interactions: Nirmatrelvir must be administered with ritonavir to achieve sufficient therapeutic plasma concentrations. Adults (18 and older) can decide which booster to get, though Pfizer and Moderna boosters are preferred in most situations, per the CDC. Early remdesivir to prevent progression to severe COVID-19 in outpatients. Can vaccine from different manufacturers be used for the COVID-19 primary series? The EUA states that ritonavir-boosted nirmatrelvir is not recommended for patients with an eGFR of <30 mL/min until more data are available to establish appropriate dosing.3 Additional information is available in the initial FDA Center for Drug Evaluation and Research review for the EUA of ritonavir-boosted nirmatrelvir.15 Clinical experience on the use of ritonavir-boosted nirmatrelvir in patients who require hemodialysis is limited.24 Based on limited data, some groups have proposed dosing adjustments for ritonavir-boosted nirmatrelvir in patients with an eGFR of <30 mL/min and those who require hemodialysis.25-27 A clinical trial (ClinicalTrials.gov Identifier NCT05487040) that will evaluate the use of ritonavir-boosted nirmatrelvir in patients with COVID-19 and severe renal impairment is currently underway. For information on using ritonavir-boosted nirmatrelvir in pediatric patients, see Special Considerations in Children, Therapeutic Management of Nonhospitalized Children With COVID-19, and Therapeutic Management of Hospitalized Children With COVID-19. Rebound phenomenon after nirmatrelvir/ritonavir treatment of coronavirus disease-2019 in high-risk persons. The mechanisms of action for both nirmatrelvir and ritonavir and the results of animal studies of ritonavir-boosted nirmatrelvir suggest that this regimen can be used safely in pregnant individuals. My patient is asking for an antibody test to decide whether to get vaccinated (or revaccinated). Viral and symptom rebound in untreated COVID-19 infection. Everyone ages 6 months and older is recommended to receive 1 bivalent mRNA booster dose after completion of any FDA-approved or FDA-authorized monovalent primary series or previously received monovalent booster dose(s) with the following exception: children age 6 months4 years who receive a 3-dose Pfizer-BioNTech primary series are not authorized to receive a booster dose at this time regardless of which Pfizer-BioNTech vaccine (i.e., monovalent or bivalent) was administered for the third primary series dose. CDC Director Dr. Rochelle P. Walensky urged individuals who are eligible to get the booster and said in a press release, "There is no bad time to get your COVID-19 booster." Massachusetts state public officials say the boosters will be available in the Bay State Monday. A bivalent mRNA vaccine is recommended for the booster dose. Saving Lives, Protecting People. Below are three scenarios and the recommended action: If your patient received the primary series before or during treatment:Revaccinate the patient with the primary series and administer 1 bivalent mRNA booster dose at least 2 months after repeating the primary series. Vaccine effectiveness might also be increased with an interval longer than 3 or 4 weeks. Most experts agree that vaccines can offer a more reliable and effective immune boost than a natural infection can. Determining the time course of CYP3A inhibition by potent reversible and irreversible CYP3A inhibitors using a limited sampling strategy. CDC periodically issues guidance and information on topics related to COVID-19, including the COVID-19 vaccine, data, and other topics. Longer treatment courses of ritonavir-boosted nirmatrelvir are not authorized by the current EUA, and there are insufficient data on the efficacy of administering a second course. What is the guidance for a use of the monovalent Novavax COVID-19 vaccine for a booster dose? Continue with the recommended vaccination schedule (i.e., complete the primary series with a monovalent Pfizer-BioNTech vaccine, then administer a bivalent booster dose at least 2 months after completion of the primary series). Everyone who can get a vaccine, should get one, the CDC stressed. Novavax monovalent COVID-19 Vaccine may be used as a booster dosein limited situationsfor people ages 18 years and older. Because of the potential for significant drug-drug interactions with concomitant medications, this regimen may not be the optimal choice for all patients. People who had severe illness with COVID-19 might experience organ damage affecting the heart, kidneys, skin and brain. Should they be vaccinated against COVID-19? You can review and change the way we collect information below. For people with a history of GBS, as for the general population, mRNA (i.e., Moderna or Pfizer-BioNTech) and Novavax COVID-19 vaccines are recommended for the primary series, and an age-appropriate mRNA vaccine is recommended for the booster dose. Anyone can read what you share. Wearing a mask for 10 days after exposure may reduce the risk of spreading COVID-19 to others. 2022. The EPIC-HR trial enrolled nonhospitalized adults with mild to moderate COVID-19 who were not vaccinated and who were at high risk of progressing to severe disease. Ranganath N, OHoro JC, Challener DW, et al. Those who have been within 6 feet of someone with COVID for a cumulative total of at least 15 minutes over a 24-hour period should quarantine for five days if unvaccinated or more than six. It is considered a vaccine administration error; you are required to report COVID-19 vaccine administration errors to the Vaccine Adverse Event Reporting System (VAERS). An official website of the United States government. Nirmatrelvir-ritonavir and viral load rebound in COVID-19. Available at: Antoine Brown P, McGuinty M, Argyropoulos C, et al. If a patient requires hospitalization after starting treatment, the full 5-day treatment course of ritonavir-boosted nirmatrelvir should be completed unless there are drug-drug interactions that preclude its use. The trial demonstrated that starting ritonavir-boosted nirmatrelvir within 5 days of symptom onset in these patients reduced the risk of hospitalization or death through Day 28 by 89% compared to placebo.3,4 This efficacy is comparable to remdesivir (87% relative reduction)5 and greater than the efficacy reported for molnupiravir (31% relative reduction).6 However, these agents have not been directly compared in clinical trials. Vaccines provide a tailored set of instructions for the immune system to use in the absence of any distractions, such as an active infection, said Paul Thomas, an immunologist at St. Jude Childrens Research Hospital in Memphis. test, though this isnt a C.D.C. Federal health officials continue to recommend that everyone get vaccinated and boosted, regardless of whether theyve had Covid-19 in the past. The immunity you gain after a Covid-19 infection might not be enough to fend off the virus again. See the latest guidance from CDC for Minimizing the Impact of COVID-19 on Individual Persons, Communities, and Healthcare Systems. Before prescribing ritonavir-boosted nirmatrelvir, clinicians should carefully review the patients concomitant medications, including over-the-counter medications, herbal supplements, and recreational drugs, to evaluate potential drug-drug interactions. The bivalent booster dose is administered at least 2 months after completion of the primary series. `D[+F78Le Z;bWXj (q ` 4 The CDC estimates about 200 million Americans 12 and older are eligible for the updated shot. Stopping lopinavir/ritonavir in COVID-19 patients: duration of the drug interacting effect. Available at: Centers for Disease Control and Prevention. Jha said everyone else age 12 or older should get a booster shot as soon as they can, particularly the elderly, people with serious medical conditions and those with weak immune systems. People who were initially immunized with . COVID-19 vaccines can be administered any time after receipt of EVUSHELD. For Healthcare Professionals: Ending Isolation and Precautions for People with COVID-19 When to Isolate Ritonavir-boosted nirmatrelvir is not recommended for patients with known or suspected severe hepatic impairment (i.e., Child-Pugh Class C), and it should be used with caution in patients with pre-existing liver diseases, liver enzyme abnormalities, or hepatitis. 2022. COVID-19 supplemental clinical guidance #4: nirmatrelvir/ritonavir (Paxlovid) use in patients with advanced chronic kidney disease and patients on dialysis with COVID-19. However, some data indicate that the tablets can be split or crushed if necessary. New COVID-19 booster shots specially formulated to fight multiple omicron variants are available now for children and adults ages 12 and over. hb```, cbM The role of combination antiviral therapy or a longer treatment duration in treating patients who are severely immunocompromised is not yet known. hbbd```b``^"HZ&5"R`2D*z} 8w&d0LG2012se)"3 Millions of people who have recently developed Covid-19 may have some new questions about their immunity. Patients who were randomized within 3 days of symptom onset (n = 1,379) were included in the modified intention-to-treat (mITT) analysis. We want to hear from you. Adults 18 and older who got Moderna can get boosted . Both situations are considered vaccine administration errors and should be reported to Vaccine Adverse Event Reporting System (VAERS). The CDC recently expanded booster recommendations to. For more information on the recommended vaccination, see COVID-19 vaccination schedule for people who are not moderately or severely immunocompromised. Anyone who was infected can experience post-COVID conditions. If a dose is administered earlier than the grace period, see Appendix D for guidance on corrective actions. People who are Moderately or Severely Immunocompromised, Vaccination and SARS-CoV-2 Laboratory Testing, Considerations Involving Pregnancy, Lactation, and Fertility, Centers for Disease Control and Prevention. People ages 18 years and older who completed primary vaccination using any COVID-19 vaccine and havenotreceived any previous booster dose(s) (including any previous monovalent or bivalent mRNA booster dose[s]) may receive a monovalent Novavax booster dose at least 6 months after completion of the primary series if they are unable to receive an mRNA vaccine (i.e., mRNA vaccine contraindicated or not available) or unwilling to receive an mRNA vaccine and would otherwise not receive a booster dose. For more information see: ATAGI guidance on myocarditis and pericarditis after mRNA COVID-19 vaccines. The CDC advises that unvaccinated individuals who have contracted COVID-19 wait until symptoms have improved and at least ten days have passed since their positive test to get vaccinated.. Interim Clinical Considerations for COVID-19 Vaccination, COVID-19 Vaccine FAQs for Healthcare Professionals, People who are moderately or severely immunocompromised, Considerations for extended intervals for COVID-19 vaccine primary series, Vaccine Adverse Event Reporting System (VAERS), timing, spacing, age transitions, and interchangeability of COVID-19 vaccines, Coadministration of COVID-19 vaccines with other vaccines, Interim Clinical Considerations for Use of JYNNEOS and ACAM2000 Vaccines during the 2022 U.S. Monkeypox O, Timing, spacing, age transitions, and coadministration of COVID-19 vaccines, Special Situations for COVID-19 Vaccination of Children and Adolescents: Age Transitions and Interchangeability, Interim COVID-19 Immunization Schedule for 6 Months of Age and Older, Vaccine administration errors and deviations, vaccine administration errors and deviations, Interchangeability of COVID-19 vaccine products, people who received COVID-19 vaccine outside the United States, Guidance for COVID-19 vaccination for people who are moderately or severely immunocompromised, COVID-19 Vaccines for people who are moderately or severely immunocompromised, considerations for COVID-19 revaccination, people who are moderately or severely immunocompromised, currently authorized SARS-CoV-2 antibody tests, Antibody (Serology) Testing for COVID-19:Information for Patients and Consumers, Interim Guidelines for COVID-19 Antibody Testing, COVID-19 vaccination and SARS-CoV-2 infection, Appendix A: Guidance for use of Janssen COVID-19 Vaccine, COVID-19 Vaccines While Pregnant or Breastfeeding, FDA-approved or FDA-authorized COVID-19 vaccine, COVID-19 vaccination schedule for people who are not moderately or severely immunocompromised, Guidance for use of Janssen COVID-19 Vaccine, Use of the Janssen (Johnson & Johnson) COVID-19 Vaccine, COVID-19 vaccination schedule for people who arenot moderately or severely immunocompromised, National Center for Immunization and Respiratory Diseases, Use of COVID-19 Vaccines in the U.S.: Appendices, FAQs for the Interim Clinical Considerations, Myocarditis and Pericarditis Considerations, Jurisdictions: Vaccinating Older Adults and People with Disabilities, Vaccination Sites: Vaccinating Older Adults and People with Disabilities, Vaccinating Patients upon Discharge from Hospitals, Emergency Departments & Urgent Care Facilities, Vaccines for Children Program vs. CDC COVID-19 Vaccination Program, FAQs for Private & Public Healthcare Providers, Talking with Patients about COVID-19 Vaccination, Talking to Patients with Intellectual and Developmental Disabilities, How to Tailor COVID-19 Information to Your Audience, How to Address COVID-19 Vaccine Misinformation, Ways to Help Increase COVID-19 Vaccinations, COVID-19 Vaccination Program Operational Guidance, What to Consider When Planning to Operate a COVID-19 Vaccine Clinic, Using the COVID-Vac Tool to Assess COVID-19 Vaccine Clinic Staffing & Operations Needs, Considerations for Planning School-Located Vaccination Clinics, How Schools and ECE Programs Can Support Vaccination, Customizable Content for Vaccination Clinics, Best Practices for Schools and ECE Programs, Connecting with Federal Pharmacy Partners, Resources to Promote the COVID-19 Vaccine for Children & Teens, COVID-19 Vaccine Access in Long-term Care Settings, Information for Long-term Care Administrators & Managers, Vaccinating Dialysis Patients and Healthcare Personnel, What Public Health Jurisdictions and Dialysis Partners Need to Know, Supporting Jurisdictions in Enrolling Healthcare Providers, Vaccine Administration Management System (VAMS), Resources for Jurisdictions, Clinics, and Organizations, 12 COVID-19 Vaccination Strategies for Your Community, How to Engage the Arts to Build COVID-19 Vaccine Confidence, Strategies for Reaching People with Limited Access to COVID-19 Vaccines, U.S. Department of Health & Human Services. (Meaning, if you had a mild infection, its been at least five days since your symptoms started, your symptoms are improving and youve been fever-free for at least 24 hours without the help of medications.). Ages 6 years and older: 1 bivalent mRNA booster dose (Moderna or Pfizer-BioNTech) regardless of which vaccine they received for their primary series. Booster doses All adults can get a booster if it's been 6 months or longer since their last COVID-19 booster or confirmed infection (whichever is most recent) for additional protection against severe illness from COVID. Although ritonavir-boosted nirmatrelvir demonstrated a clinical benefit during the EPIC-HR trial, the benefits in unvaccinated people who are at low risk of progression to severe disease or in vaccinated people who are at high risk of progression to severe disease are unclear. But more than half of fully vaccinated Americans. And for some, Dr. Ellebedy added, there can be a benefit to waiting even longer. The child should receive 1 bivalent Pfizer-BioNTech booster dose when they turn age 5 years, and it has been at least 2 months since completing their primary series. One of the best ways scientists know how to measure that response is to look at how many antibodies youve produced. Can a monovalent mRNA vaccine (i.e., Moderna or Pfizer-BioNTech) be used for the booster dose? Resulting in a higher-than-authorized dose: Do not repeat dose. "If you've had a recent infection or were recently vaccinated, it's reasonable to wait a few months," Jha told reporters during a new conference Tuesday. And when is the optimal time to get it? The EPIC-SR trial, which included both of these populations, found that ritonavir-boosted nirmatrelvir did not reduce the duration of symptoms and did not have a statistically significant effect on the risk of hospitalization or death compared to placebo, although the event rates were low.7 Some observational studies evaluated the effect of ritonavir-boosted nirmatrelvir in vaccinated individuals who were at high risk of progression to severe COVID-19, but because of the limitations of observational studies, these data are not definitive.8-10 For information on treatment considerations for vaccinated individuals, see Therapeutic Management of Nonhospitalized Adults With COVID-19. CDC recommends COVID-19 vaccination for all people who are pregnant, breastfeeding, recently pregnant, trying to get pregnant now, or who might become pregnant in the future. The Centers for Disease Control and Prevention last week cleared boosters that target the dominant omicron BA.5 subvariant. Vaccinators and clinic administrators should not deny COVID-19 vaccination to a person because of a lack of documentation. When a child who received a mixed primary dose series turns age 5 years, the child may receive 1 bivalent booster dose with either Moderna or Pfizer-BioNTech vaccine. There were no deaths in the ritonavir-boosted nirmatrelvir arm and 13 deaths in the placebo arm. The CDC cleared a fourth dose of the old vaccines in March for this age group. Age 5 years and received Pfizer-BioNTech primary series: 1 bivalent Pfizer-BioNTech booster dose. It isn't clear how long these effects might last. If they have not yet received a booster shot, do they still need to get one? In a prebirth-to-lactation study, an 8% decrease in body weight was observed on Postnatal Day 17 in the offspring of rats who received nirmatrelvir and had systemic exposures that were 8 times higher than the clinical exposures at the authorized human dose. Nirmatrelvir, an orally active MPRO inhibitor, is a potent inhibitor of SARS-CoV-2 variants of concern. COVID-19 rebound after Paxlovid treatment. We take your privacy seriously. A Division of NBCUniversal. This can have a significant impact on quality of life and function. Deo R, Choudhary MC, Moser C, et al. What is the guidance for vaccinating infants of mothers who received COVID-19 vaccine and/or had COVID-19 or SARS-CoV-2 infection before or during pregnancy? Severely immunocompromised patients can experience prolonged periods of SARS-CoV-2 replication, which may lead to rapid viral evolution. These cookies may also be used for advertising purposes by these third parties. Novavax COVID-19 vaccine for booster vaccination and Janssen COVID-19 Vaccine for primary series and booster vaccination should only be used in limited situations. This page has answers to commonly asked questions about the Interim Clinical Considerations for COVID-19 Vaccination. Can COVID-19 vaccines be administered at the same time as an orthopoxvirus (monkeypox) vaccine? Pillaiyar T, Manickam M, Namasivayam V, Hayashi Y, Jung SH. According to federal officials, there are no restrictions for getting the booster around a recent COVID infection. Yes. People who received three shots with the original vaccines and then caught Covid had more than 70% protection against infection from the omicron BA.1 and BA.2 variants, according to a study published inthe New England Journal of Medicineby Weill Cornell Medicine in Qatar. No increased risk of GBShas been identified with receipt of mRNA COVID-19 vaccines. Heres what to know. Which COVID-19 vaccines are recommended for people with a history of Guillain-Barre syndrome (GBS)? The optimal timing will depend on your individual circumstances, including how severe your illness was, how long its been since your symptoms resolved and what your risk for re-exposure is. A fourth dose was about 56% effective at preventing hospitalization from omicron BA.5 four months after receiving the shot, according to CDC data. You will be subject to the destination website's privacy policy when you follow the link. University of Liverpool. Looking for U.S. government information and services. He also said that it takes "three to four days" after getting the vaccine for your body to start creating antibodies and longer to develop full protection. Among the 2,085 patients who were randomized within 5 days of symptom onset (mITT1 analysis), COVID-19-related hospitalizations and all-cause deaths occurred in 8 of 1,039 patients (0.77%) in the ritonavir-boosted nirmatrelvir arm and in 66 of 1,046 patients (6.3%) in the placebo arm (89% relative risk reduction; 5.6% estimated absolute reduction; 95% CI, 7.2% to 4.0%; P < 0.001). People who previously received SARS-CoV-2 antibody products (anti-SARS-CoV-2 monoclonal antibodies or convalescent plasma) as part of COVID-19 treatment, post-exposure prophylaxis, or pre-exposure prophylaxis can be vaccinated at any time; COVID-19 vaccination does not need to be delayed following receipt of monoclonal antibodies or convalescent plasma. The booster provides real material help against preventing you from getting Omicron, Dr. Thomas said. People who recently had SARS-CoV-2 infection may consider delaying their primary series or booster COVID-19 vaccine dose by 3 months from symptom onset or positive test (if infection was asymptomatic). The decision about the second booster was especially intended for people ages 65 and up or ages 50 and up with chronic health conditions who had received their first booster dose at least four. For more information, see Coadministration of COVID-19 vaccines with other vaccines. Jha told reporters in July that breakthrough infections in people who are vaccinated have become more common since the omicron BA.5 variant became the dominant form of Covid over the summer. See, The person would otherwise not complete the primary series. Children in this age group who have not yet received the third Pfizer-BioNTech primary dose are recommended to receive a bivalent Pfizer-BioNTech dose as the third primary dose. People with a history of Bells palsy may receive any currently FDA-approved or FDA-authorized COVID-19 vaccine: mRNA (i.e., Moderna or Pfizer-BioNTech) and Novavax COVID-19 vaccines are recommended for the primary series and an age-appropriate mRNA vaccine is recommend for the booster dose. Stader F, Khoo S, Stoeckle M, et al. If you do not allow these cookies we will not know when you have visited our site, and will not be able to monitor its performance.