Centers for Disease Control and Prevention

National Center for Immunization and Respiratory Diseases

Photographs and images included in this presentation are licensed solely for CDC/NCIRD online and presentation use. No rights are implied or extended for use in printing or any use by other CDC CIOs or any external audiences.

Updates to Interim Clinical Considerations for 

Use of COVID-19 Vaccines

Evelyn Twentyman, MD MPH

National Center for Immunization and Respiratory Diseases

Centers for Disease Control and Prevention
Overview of implications
▪ Simple and singular for most

▪ Flexible for people at higher risk

▪ Customized recommendations for young children

Implications of the new recommendations
▪ Simple and singular for most

▪ Flexible for people at higher risk

▪ Customized recommendations for young children

Implications of the new recommendations
Previous recommendations for people aged ≥6 years 

without immunocompromise
New recommendations for people aged ≥6 years without 

immunocompromise who have not yet received a bivalent 

mRNA dose

One bivalent 

mRNA dose
New recommendations for people aged ≥6 years without immunocompromise who 

have not yet received a bivalent mRNA dose, regardless of COVID-19 vaccination 

history

One bivalent 

mRNA dose

≥1 monovalent

Moderna dose

≥1 monovalent 

Novavax dose

≥1 monovalent 

Janssen dose

No COVID-19 

vaccine doses

≥1 monovalent

Pfizer-BioNTech

dose
New recommendations for aged ≥6 years without 

immunocompromise who have already received a bivalent 

mRNA dose

One bivalent 

mRNA dose

Vaccination is complete.

No doses are indicated at this time.
▪ Simple and singular for most

▪ Flexible for people at higher risk

▪ Customized recommendations for young children

Implications of the new recommendations
Flexible for people at higher risk of severe COVID-19:

People aged ≥65 years who have not yet received a bivalent 

mRNA dose

One bivalent 

mRNA dose

Optional additional 

bivalent mRNA dose

At least 

4 months
Flexible for people at higher risk of severe COVID-19:

People aged ≥65 years who have already received a bivalent 

mRNA dose

One bivalent 

mRNA dose

Optional additional 

bivalent mRNA dose

At least 

4 months
New flexibility for people at higher risk of severe COVID-19:

People aged ≥6 years with immunocompromise* who have 

already received a bivalent mRNA dose

*Including those with imminent immunocompromise (e.g., prior to organ transplant; other causes.)

One bivalent 

mRNA dose

Optional additional 

bivalent mRNA dose

At least 

2 months

Additional 

bivalent mRNA 

doses as needed 

At least 

2 months Stem cell transplant

CAR-T therapy

B-cell depletion

Others
▪ Simple and singular for most

▪ Flexible for people at higher risk

▪ Customized recommendations for young children

Implications of the new recommendations
Doses previously recommended:

Moderna:

• 2 monovalent primary series doses +

• 1 bivalent booster dose

Pfizer:

• 2 or 3 monovalent primary series 

doses +

• 1 bivalent primary series dose

Transitioning from the monovalent to the bivalent era for 

children without immunocompromise aged 6 months – 4 years

Doses now recommended:

Customized by COVID-19 

vaccination history such that all 

children receive:

• At least 2 vaccine doses in total 

including

• At least 1 bivalent dose
Number of

doses

indicated, by

manufacturer

Vaccination complete.

COVID-19 vaccination 

status April 2023

Previously received vaccine(s)

COVID-19 vaccination algorithm for people without immunocompromise, ages 6 months–4 years, mRNA vaccines April 2023*

Unvaccinated Vaccinated

1 dose bivalent Moderna

1 dose 

monovalent 

Moderna

2 doses 

monovalent 

Moderna

2 doses 

bivalent 

PfizerBioNTech

1 dose 

monovalent 

PfizerBioNTech

2 doses 

monovalent 

PfizerBioNTech

3 doses 

monovalent 

PfizerBioNTech

1 dose bivalent PfizerBioNTech

2 doses 

monovalent 

Moderna and 1

dose bivalent 

Moderna

2 doses 

monovalent 

Pfizer-BioNTech 

and 1 dose 

bivalent PfizerBioNTech

*To see product-specific doses and intervals of administration, see Table 1 and 2 forthcoming in Interim Clinical Considerations, forthcoming.

2 doses 

bivalent 

Moderna

OR

3 doses 

bivalent 

PfizerBioNTech
Doses previously recommended:

Moderna:

• 2 monovalent primary series doses +

• 1 bivalent booster dose

Pfizer:

• 2 or 3 monovalent primary series 

doses +

• 1 bivalent primary series dose

Transitioning from the monovalent to the bivalent era for 

children without immunocompromise aged 5 years

Doses now recommended:

Customized so that Moderna

recipients receive:

• At least 2 vaccine doses in total 

including

• At least 1 bivalent dose

And Pfizer recipients receive: 

• At least 1 bivalent dose
Vaccination complete.

Number of

doses

Indicated, by

manufacturer

Previously received vaccine(s)

COVID-19 vaccination 

status April 2023 Unvaccinated Vaccinated

1 or more doses 

monovalent 

Moderna

1 or more doses 

monovalent 

Pfizer-BioNTech

Any doses 

monovalent 

Pfizer-BioNTech 

and 1 dose 

bivalent PfizerBioNTech

2 doses 

monovalent 

Moderna and 1

dose bivalent 

mRNA

OR

2 doses 

bivalent 

Moderna

1 dose 

bivalent 

PfizerBioNTech

1 dose 

bivalent 

PfizerBioNTech

COVID-19 vaccination algorithm for people without immunocompromise, age 5 years, mRNA vaccines April 2023*

*To see product-specific doses and intervals of administration, see reference Table 1 in Interim Clinical Considerations, forthcoming

1 dose 

bivalent 

Moderna
▪ Adults and children aged 6 years and older are up to date with COVID-19 vaccines if they got a bivalent 

(updated) COVID-19 vaccine. 

▪ Children 6 months through 5 years of age who received the Pfizer-BioNTech COVID-19 vaccine are up to 

date if:

– They are 6 months to 4 years of age and got at least 3 COVID-19 vaccine doses, including at least one 

bivalent (updated) COVID-19 vaccine dose. 

– They are 5 years of age and got at least 1 bivalent (updated) COVID-19 vaccine dose. 

▪ Children 6 months through 5 years of age who got the Moderna COVID-19 vaccine are up to date if they got 

at least two Moderna COVID-19 vaccine doses, including at least one bivalent (updated) COVID-19 vaccine 

dose. 

▪ You may be eligible for additional COVID-19 vaccine doses if: 

– You are 65 years of age and older and got your first bivalent (updated) COVID-19 vaccine booster 4 or 

more months ago.

– You are moderately or severely immunocompromised and received a bivalent (updated) COVID-19 

vaccine booster 2 or more months ago.

▪ If you are unable or choose not to get a recommended bivalent mRNA vaccine, you will be up to date if you 

got the Novavax COVID-19 vaccine doses approved for your age group. 

Stay Up to Date with COVID-19 Vaccines 
Implications for vaccine providers
Moderna

Pfizer-BioNTech

Novavax

Janssen

Fewer COVID-19 Vaccine Products in Use 

Bivalent Bivalent

Bivalent Bivalent Bivalent

Bivalent Bivalent

Bivalent Bivalent Bivalent

All remaining Janssen vaccine doses 

expire by May 6th 2023

Manufacturer Products Previously in Use Products Now in Use
▪ CDC’s Interim Clinical Considerations for Use of Authorized 

COVID-19 Vaccines will be updated with comprehensive tables 

of vaccine doses and dosages indicated

• For each age group

• By history of COVID-19 vaccines received, for children ages 6 months 

through 5 years

▪ Revision of clinical guidance materials is underway

▪ COCA Call to be held May 11th, 2023*

Additional help for providers is on the way

*Please visit https://emergency.cdc.gov/coca/ for complete details
Implications for public health
Bivalent COVID-19 vaccine coverage is low. 

COVID-19 Data Tracker, last updated April 13, 2023, CDC COVID Data Tracker: Vaccinations in the US

16.7% of the total U.S. 

population has received a 

bivalent COVID-19 vaccine.

20.2% of adults aged 

≥18 years in the U.S. have 

received a bivalent COVID19 vaccine.
COVID-19 Data Tracker, last updated April 13, 2023, https://covid.cdc.gov/covid-data-tracker/#vaccination-demographics-trends

43%

22%

12%

7%

8%

5%

> 65 years

50–64 years

25–49 years

18–24 years

12–17 years

5–11 years

2–4 years

<2 years

Bivalent COVID-19 Vaccination Coverage by Age

Bivalent COVID-19 vaccine coverage generally decreases with

decreasing age.
COVID-19 Data Tracker, last updated April 14, 2023, https://covid.cdc.gov/covid-data-tracker/#vaccination-demographics-trends

Bivalent COVID-19 vaccine coverage is lower among Black, nonHispanic, Hispanic/Latino, and Native Hawaiian or Other Pacific 

Islander.

17%

12%

24%

9%

9%

22%

15%

White, NH

NHOPI, NH

Multiracial, NH

Hispanic/Latino

Black, NH

Asian, NH

AI/AN, NH

Bivalent COVID-19 Vaccination Coverage by Race/Ethnicity
COVID-19 Data Tracker, last updated April 14, 2023, https://covid.cdc.gov/covid-data-tracker/#vaccination-demographics-trends

Bivalent COVID-19 vaccine coverage is lower among those with lower 

income.

39%

29%

27%

Above poverty,

income >$75K

Above poverty,

income <$75K

Below poverty

Bivalent COVID-19 vaccine coverage by income among adults aged ≥18 years
COVID-19 Data Tracker, last updated April 14, 2023, https://covid.cdc.gov/covid-data-tracker/#vaccination-demographics-trends

Bivalent COVID-19 vaccine coverage is lower among those without 

health insurance.

35%

15%

With Health

Insurance

Without

Health

Insurance

Bivalent COVID-19 vaccine coverage among adults aged ≥18 years by insurance status
▪ COVID-19 vaccines continue to be the most effective tool we have to prevent serious 

illness, hospitalization and death from COVID-19 

– Uptake of the updated (bivalent) COVID-19 vaccines is not yet equitable, and 

remains generally low

▪ Simple recommendations are easier to communicate, which may improve vaccine 

uptake

▪ CDC is continuing to work toward additional materials for vaccine providers, 

clinicians and the general public to make it easy for everyone to get up to date and 

stay up to date with COVID-19 vaccines

Reflections and Next Steps
▪ Sara Oliver

▪ Hannah Rosenblum

▪ Mary Chamberland

▪ Susan Goldstein

▪ Elisha Hall

▪ JoEllen Wolicki

▪ Katherine Fleming-Dutra

▪ Ruth Link-Gelles

▪ Monica Godfrey

▪ Danielle Moulia

▪ Megan Wallace 

▪ Lauren Roper

▪ Amadea Britton

▪ Sarah Meyer

▪ Julianne Gee

▪ Heather Scobie

▪ Sierra Scarbrough

▪ Yvonne Bolen

▪ Jefferson Jones

▪ Noelle Molinari

▪ Aron Hall

▪ Barbara Mahon

▪ Data Analytics and Visualization Task Force

▪ Coronavirus and other Respiratory Viruses 

Division

▪ Immunization Services Division

▪ National Center for Immunization and Respiratory 

Diseases

Acknowledgments
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.

Photographs and images included in this presentation are licensed solely for CDC/NCIRD online and presentation use. No rights are implied or extended for use in printing or 

any use by other CDC CIOs or any external audiences.
Additional Flowcharts
Vaccination complete. Optional additional doses as needed**

Previously received vaccine(s)

Number of 

doses 

Indicated, by 

manufacturer 

COVID-19 vaccination 

status April 2023

1 or more

doses 

monovalent 

Moderna

2 dose 

monovalent 

Pfizer-BioNTech 

and 1 dose 

bivalent mRNA

2 doses 

monovalent 

Moderna and 1

dose bivalent 

mRNA

1 dose bivalent Moderna

1 dose bivalent Pfizer-BioNTech

OR

1 or more

doses 

monovalent 

PfizerBioNTech

Unvaccinated Vaccinated

COVID-19 vaccination algorithm for people who are NOT moderately or severely immunocompromised, age 6 years and older, mRNA vaccines April 2023*

*To see product-specific doses and intervals of administration, see reference Table 1 in Interim Clinical Considerations, forthcoming. 

**People ages 65+ have the option to receive 1 additional bivalent mRNA dose at least 4 months after the first dose of a bivalent mRNA vaccine. 
Tables
COVID-19 vaccination history Bivalent vaccine Number of bivalent 

doses indicated Dosage (mL/ug) Vaccine vial cap and label colors Interval between doses

Unvaccinated

Moderna

___or___

2

0.25 mL/25 ug Dark blue cap; gray label border Dose 1 and Dose 2: 

4–8 weeks

Pfizer BioNTech

3

0.2 mL/3 ug Maroon

Dose 1 and Dose 2:

3–8 weeks

Dose 2 and dose 3:

At least 8 weeks

1 dose monovalent Moderna Moderna 1 0.25 mL/25 ug Dark blue cap; gray label border 4-8 weeks after monovalent dose

2 doses monovalent Moderna Moderna 1 0.2 mL/10 ug Dark pink cap; yellow label border At least 8 weeks after last monovalent dose

2 doses monovalent Moderna 

and 1 dose bivalent Moderna 

NA; previously received 1 

bivalent vaccine dose NA NA NA NA

1 dose monovalent PfizerBioNTech Pfizer BioNTech 2 0.2 mL/3 ug Maroon

Dose 1: 3–8 weeks after monovalent dose

Dose 1 and Dose 2: At least 8 weeks 

2 doses monovalent PfizerBioNTech Pfizer BioNTech 1 0.2 mL/3 ug Maroon At least 8 weeks after last monovalent dose

3 doses monovalent PfizerBioNTech Pfizer BioNTech 1 0.2 mL/3 ug Maroon At least 8 weeks after last monovalent dose

2 doses monovalent PfizerBioNTech and 1 dose bivalent 

Pfizer-BioNTech

NA; previously received 1 

bivalent vaccine dose NA NA NA NA

Table 1. COVID-19 vaccination schedule for people who are NOT moderately or severely immunocompromised 

by COVID-19 vaccination history, April 2023: Ages 6 months–4 years
COVID-19 vaccination history Bivalent vaccine Number of bivalent 

doses indicated Dosage (mL/ug) Vaccine vial cap and label colors Interval between doses

Unvaccinated

Moderna

___or___

2

0.25 mL/25 ug Dark blue cap; gray label border Dose 1 and Dose 2: 

4–8 weeks

Pfizer BioNTech 1 0.2 mL/10 ug Orange

1 dose monovalent Moderna 

Moderna

___or___

1 0.25 mL/25 ug Dark blue cap; gray label border 4–8 weeks after monovalent dose 

Pfizer BioNTech 1 0.2 mL/10 ug Orange At least 8 weeks after monovalent dose 

2 doses monovalent Moderna 

Moderna

___or___

1 0.2 mL/10 ug Dark pink cap; yellow label border At least 8 weeks after last monovalent dose

Pfizer BioNTech 1 0.2 mL/10 ug Orange At least 8 weeks after last monovalent dose 

2 doses monovalent Moderna 

and 1 dose bivalent mRNA 

NA; previously received 

1 bivalent vaccine dose NA NA NA NA

1 or more doses monovalent 

Pfizer-BioNTech Pfizer-BioNTech1

0.2 mL/10 ug Orange At least 8 weeks after last monovalent dose 

2 doses monovalent PfizerBioNTech and 1 dose bivalent 

Pfizer-BioNTech

NA; previously received 

1 bivalent vaccine dose NA NA NA NA

Table 1. COVID-19 vaccination schedule for people who are NOT moderately or severely immunocompromised 

by COVID-19 vaccination history, April 2023: Age 5 years