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People with certain health conditions that make them moderately or severely immunocompromised may be given a fourth injection of COVID-19 mRNA, according to updated guidance from the U.S. Centers for Disease Control and Prevention.

The CDC cleared a third dose for some immunocompromised people 18 and older in August. He said a third dose, rather than a booster – the CDC makes a distinction between the two – was needed because the immunocompromised may not have had a full immune response from the first two doses.

A study from Johns Hopkins University this summer showed that immunocompromised people vaccinated were 485 times more likely to end up in hospital or die from COVID-19 compared to most people vaccinated. In small studies, the CDC said, fully immunized immunocompromised people accounted for about 44% of breakthrough cases requiring hospitalization. People who are immunocompromised are also more likely to pass the virus on to people who have been in close contact with them.

The United States Food and Drug Administration has also authorized booster shots of the three available vaccines for some people and this would include those who are immunocompromised, according to the CDC.

Research has shown that a booster dose improves the antibody response to the vaccine in some immunocompromised people.

This would make a fourth shot at least six months after completing the third dose of mRNA vaccine. At this time, the CDC does not have a recommendation regarding the fourth move. People should speak to their doctors to determine if this is necessary, the CDC says.

People who are moderately to severely immunocompromised include those on active cancer therapy for blood cancers or tumors, some organ and stem cell transplant recipients, people with advanced or untreated HIV, and those who are taking high-dose corticosteroids or other medicines that may suppress their immune system. The CDC estimates that about 9 million people living in the United States, or about 2% of the population, fall into this category.

Immunocompromised people who have received the Johnson & Johnson single dose vaccine should be boosted at least two months after their initial vaccine. People who choose a Moderna vaccine as a booster, even though they received a different vaccine as their first dose, should receive the half-dose size vaccine allowed as a booster for the Moderna vaccine, the CDC said.

Even if they are vaccinated, the CDC recommends that people with conditions that compromise their immune systems try to avoid crowds and poorly ventilated spaces, and wear a mask in indoor public spaces.

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