cdc.gov/coronavirus

COVID-19 Vaccine: 

Considerations for Future Planning

Sara Oliver, MD, MSPH

ACIP Meeting

February 24, 2023
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 1st and 2nd dose 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 

0

1,000,000

2,000,000

3,000,000

4,000,000

5,000,000

6,000,000

7,000,000

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 

1st booster authorization 

2nd booster authorization Bivalent booster authorization 

Doses Administered
COVID-19 message fatigue challenges vaccine uptake

 Recent studies reflect profound COVID-19 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, including but not limited to:

–

–

–

People living in rural areas4

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 

in 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–December 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. Presentation 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, 2023

Trends 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

0

4M

2M

Positive tests / Proportion of viral lineages
Seroprevalence by Vaccine and Infection History Among 

Adult U.S. Blood Donors, January–June 2022

Q1 = Jan.–Mar. 2022 

Q2 = Apr.–Jun. 2022

43

35 35

25

44 38

61 56

68 67

30

37 33

43

31 36

18 24

17 20

20 22 25 28 18 21 9 10

8 9

8 6 7 4 7 5

12 10 6 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 over

Seroprevalence

Age (years) and quarter

No immunity

Infection only induced

immunity

Both vaccine and infection

induced immunity

Vaccine only induced

immunity

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

0

100

200

300

400

500

600

700

Rate 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/#covidnethospitalizations-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 and/or

– Due to development of new immune 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-admissions

Admissions 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 conditions, 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.htm

 Time 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’ 

after prior infection, prior vaccination, or both

 Young children will continue to age into the vaccine recommendations at 6 months and 

could be SARS-CoV-2 naive

 Some population of young 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 years

Parental 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

0

5

10

15

20

25

Rate per 100,000 population

Week Ending Date

6 months–<2 years 2–4 years

 Pediatric hospitalization rates are higher among children 6 months to <2 years of age, 

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
63

82

89

93

0

10

20

30

40

50

60

70

80

90

100

Mar-Apr May-Jun Jul-Aug Sep-Oct Nov-Dec

Seroprevalence (%)

Month

75

85

92

97

99

0

10

20

30

40

50

60

70

80

90

100

Mar-Apr May-Jun Jul-Aug Sep-Oct Nov-Dec

Seroprevalence (%)

Month

Pediatric SARS-CoV-2 Infection-Induced and Combined (Vaccine- and InfectionInduced) Seroprevalence from U.S. Commercial Laboratories —

March–December 2022

Source: https://covid.cdc.gov/covid-data-tracker/#pediatric-seroprevalence and unpublished data from CDC

Infection-induced 

Combined 

(vaccine- and infection-induced) 
Are there populations who still need a primary series? 

Summary

 Children ages <2 years have higher COVID-19 

hospitalization rates than older children

 Children ages <4 years are less likely to have both 

prior infection and prior vaccination

 Children have frequent visits to healthcare providers

 The Work Group discussed continued primary series 

recommendations 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 

rates 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, 2023

In 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, 2022

ICATT: 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 vaccine 

booster dose remain low

 The Work Group emphasized the importance of older adults being up to date on current 

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 COVID-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 

is particularly notable for organ or stem cell transplant recipients

 Among people with immunocompromise, recommendations prior to the bivalent 

booster allowed for up to 5 monovalent doses of COVID-19 vaccine

 Vaccine effectiveness studies are not yet sufficiently powered to evaluate 

effectiveness 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 Immunocompromised 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 Encounters 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 RealWorld 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 A et 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; 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 A et 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 

persons is lower than that of 

immunocompetent persons at 

comparable time points after dose 2 

and dose 3

 VE wanes in both immunocompetent 

and immunocompromised persons 
Should people with immunocompromise be recommended for >1 

vaccine annually?

Summary

 Immunocompromised adults can have less robust immune response to COVID-19 

vaccines

 Not currently any authorized prophylactic monoclonal antibody products for populations 

at 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 

severe 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 Hall

 Valerie 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 

Diseases

Acknowledgments
Question for ACIP

36

 Discussions 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