Interim Effectiveness of Updated 20232024 (Monovalent XBB.1.5) COVID-19 Vaccines Against COVID-19Associated … – CDC

Ruth Link-Gelles, PhD1; Elizabeth A.K. Rowley, DrPH2; Malini B. DeSilva, MD3; Kristin Dascomb, MD, PhD4; Stephanie A. Irving, MHS5; Nicola P. Klein, MD, PhD6; Shaun J. Grannis, MD7,8; Toan C. Ong, PhD9; Zachary A. Weber, PhD2; Katherine E. Fleming-Dutra, MD1; Charlene E. McEvoy, MD3; Omobosola Akinsete, MBBS3; Daniel Bride, MS10; Tamara Sheffield, MD11; Allison L. Naleway, PhD5; Ousseny Zerbo, PhD6; Bruce Fireman6; John Hansen, MPH6; Kristin Goddard, MPH6; Brian E. Dixon, PhD7,12; Colin Rogerson, MD7,13; William F. Fadel, PhD7,14; Thomas Duszynski, PhD7,15; Suchitra Rao, MBBS9; Michelle A. Barron, MD9; Sarah E. Reese, PhD2; Sarah W. Ball, ScD2; Margaret M. Dunne, MSc2; Karthik Natarajan, PhD16; Erica Okwuazi, MSc1,17; Ami B. Shah, MPH1,17; Ryan Wiegand, PhD1; Mark W. Tenforde, MD, PhD18; Amanda B. Payne, PhD1 (View author affiliations)

What is already known about this topic?

In September 2023, CDCs Advisory Committee on Immunization Practices recommended updated 20232024 (monovalent XBB.1.5) COVID-19 vaccination for all persons aged 6 months to prevent COVID-19, including severe disease, with optional additional doses for persons with immunocompromising conditions; such persons are at higher risk for severe COVID-19 and might also have reduced immune responses to vaccination.

What is added by this report?

Among adults aged 18 years with immunocompromising conditions, receipt of an updated COVID-19 vaccine provided increased protection against COVID-19associated hospitalizations compared with not receiving an updated COVID-19 vaccine. Few persons (18%) in this high-risk study population had received updated COVID-19 vaccine.

What are the implications for public health practice?

All persons with immunocompromising conditions should receive updated COVID-19 vaccination and may get additional updated COVID-19 vaccine doses 2 months after the last recommended COVID-19 vaccine.

In September 2023, CDCs Advisory Committee on Immunization Practices recommended updated 20232024 (monovalent XBB.1.5) COVID-19 vaccination for all persons aged 6 months to prevent COVID-19, including severe disease. As with past COVID-19 vaccines, additional doses may be considered for persons with immunocompromising conditions, who are at higher risk for severe COVID-19 and might have decreased response to vaccination. In this analysis, vaccine effectiveness (VE) of an updated COVID-19 vaccine dose against COVID-19associated hospitalization was evaluated during September 2023February 2024 using data from the VISION VE network. Among adults aged 18 years with immunocompromising conditions, VE against COVID-19associated hospitalization was 38% in the 759 days after receipt of an updated vaccine dose and 34% in the 60119 days after receipt of an updated dose. Few persons (18%) in this high-risk study population had received updated COVID-19 vaccine. All persons aged 6 months should receive updated 20232024 COVID-19 vaccination; persons with immunocompromising conditions may get additional updated COVID-19 vaccine doses 2 months after the last recommended COVID-19 vaccine.

On September 12, 2023, CDCs Advisory Committee on Immunization Practices recommended updated 20232024 COVID-19 vaccination with a monovalent XBB.1.5derived vaccine for all persons aged 6 months to prevent COVID-19, including severe disease (1). Most persons aged 5 years are recommended to receive 1 updated dose. Persons with moderate or severe immunocompromising conditions, who are at higher risk for severe COVID-19 and might have a decreased response to vaccination, have the option to receive additional doses, guided by the clinical judgment of a health care provider and personal preference and circumstances* (2). Understanding vaccine effectiveness (VE) among persons with immunocompromising conditions is important to guiding vaccine policy and patient and provider decisions. This analysis estimated effectiveness of updated 20232024 COVID-19 vaccines against COVID-19associated hospitalizations among adults aged 18 years with immunocompromising conditions during September 2023February 2024.

Methods for Virtual SARS-CoV-2, Influenza, and Other respiratory viruses Network (VISION) VE analyses have been reported (3). VISION is a multisite electronic health care records (EHR)based network that utilizes a test-negative design to estimate COVID-19 VE. This analysis included hospitalizations among adults aged 18 years with immunocompromising conditions and who had COVID-19like illness with SARS-CoV-2 molecular testing during the 10 days preceding admission or up to 72 hours after admission. Case-patients were persons who received a positive SARS-CoV-2 test result using a molecular test and received a negative or indeterminate or had an unknown test result for both respiratory syncytial virus and influenza, and control patients were those who received a negative SARS-CoV-2 test result using a molecular test and received a negative influenza test result or had an unknown influenza test result. Nine persons who received >1 updated COVID-19 vaccine dose were included.** Odds ratios (ORs) and 95% CIs were estimated using multivariable logistic regression comparing persons who received an updated COVID-19 vaccine dose with those who did not, irrespective of the number of previous original or bivalent COVID-19 vaccine doses received (if any), among case- and control patients. Regression models were adjusted for age, sex, race and ethnicity, calendar time, and geographic region. VE was calculated as (1 adjusted OR) 100%. Analyses were conducted using R software (version 4.3.2; R Foundation). This activity was reviewed by CDC, deemed not research, and was conducted consistent with applicable federal law and CDC policy. VISION activities were reviewed and approved by the Westat and site institutional review boards.

Among 14,586 patients with immunocompromising conditions who were hospitalized with COVID-19like illness, 1,392 case-patients and 13,194 control patients were included (Table 1). The most common immunocompromising conditions among both case-patients and control patients were solid organ malignancy (36% and 43%, respectively) and other intrinsic immune conditions or immunodeficiency (38% and 35%, respectively). A total of 195 (14%) case-patients had received an updated COVID-19 vaccine dose compared with 2,401 (18%) control patients. VE against COVID-19associated hospitalization was 38% in the first 759 days after receipt of an updated COVID-19 vaccine dose and 34% in the 60119 days after receipt of an updated dose (Table 2).

In this multisite analysis among adults with immunocompromising conditions during September 2023February 2024, receiving an updated 20232024 COVID-19 vaccine dose provided additional protection against COVID-19associated hospitalizations, compared with not receiving an updated vaccine dose. Effectiveness estimates in this report were slightly lower than those in a recently published analysis from VISION and another CDC VE network showing COVID-19 VE against COVID-19-associated hospitalizations in adults without immunocompromising conditions was approximately 50%, but this report includes the analysis of an additional month of data compared with the previous report (3). However, lower COVID-19 VE among adults with immunocompromising conditions compared with adults without immunocompromising conditions has been previously reported (4,5); persons with moderate or severe immunocompromising conditions are at higher risk for severe COVID-19 and might have decreased response to vaccination (2).

Relatively few persons in this analysis had received an updated COVID-19 vaccine dose, despite those with immunocompromising conditions being at higher risk for severe COVID-19. For example, among those with an organ or stem cell transplant, a group known to be at particularly high risk for severe COVID-19 (6), only 18% had received an updated dose, representing a missed opportunity to prevent severe COVID-19.

The findings in this report are subject to at least two limitations. First, the use of selected discharge diagnoses as surrogates for presumed immunocompromise status and the absence of medication and other relevant data might have led to misclassification of immunocompromise status, which might have biased estimated VE in either direction. Second, immunocompromising conditions are heterogeneous and likely to create differential risk for severe COVID-19, as well as differential response to vaccination (2). This analysis did not have statistical power to estimate VE by individual risk group or for those receiving more than one dose of the updated COVID-19 vaccine; however, CDC will continue to monitor VE in these groups. In addition, this analysis is subject to limitations similar to those in previous VISION VE analyses, including the potential that case-patients might have been hospitalized for reasons other than COVID-19, potential misclassification of vaccination status, no accounting for previous infection status, and potential residual confounding (3).

Receipt of an updated COVID-19 vaccine dose provided increased protection against COVID-19associated hospitalization among adults with immunocompromising conditions compared with no receipt of an updated dose. CDC will continue to monitor VE of updated COVID-19 vaccines in populations at high risk, including those with immunocompromising conditions. All persons aged 6 months should receive updated 20232024 COVID-19 vaccination; persons with immunocompromising conditions may get additional updated COVID-19 vaccine doses 2 months after the last recommended COVID-19 vaccine.

Allison Ciesla, Monica Dickerson, Josephine Mak, Abby L. Martin, Morgan Najdowski, Caitlin Ray, Emily Reeves, Ralph D. Whitehead, Jr., CDC.

1Coronavirus and Other Respiratory Viruses Division, National Center for Immunization and Respiratory Diseases, CDC; 2Westat, Rockville, Maryland; 3HealthPartners Institute, Minneapolis, Minnesota; 4Division of Infectious Diseases and Clinical Epidemiology, Intermountain Health, Salt Lake City, Utah; 5Kaiser Permanente Center for Health Research, Portland, Oregon; 6Kaiser Permanente Northern California, Oakland, California; 7Center for Biomedical Informatics, Regenstrief Institute, Indianapolis, Indiana; 8Department of Family Medicine, School of Medicine, Indiana University, Indianapolis, Indiana; 9School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado; 10Enterprise Analytics, Intermountain Health, Salt Lake City, Utah; 11Immunization Programs, Intermountain Health, Salt Lake City, Utah; 12Department of Health Policy and Management, Richard M. Fairbanks School of Public Health, Indiana University, Indianapolis, Indiana; 13Department of Pediatrics, School of Medicine, Indiana University, Indianapolis, Indiana; 14Department of Biostatistics and Health Data Science, Richard M. Fairbanks School of Public Health, Indiana University, Indianapolis, Indiana; 15Department of Epidemiology, Richard M. Fairbanks School of Public Health, Indiana University, Indianapolis, Indiana; 16Department of Biomedical Informatics, Columbia University Irving Medical Center, New York, New York; 17General Dynamics Information Technology, Falls Church, Virginia; 18Influenza Division, National Center for Immunization and Respiratory Diseases, CDC.

Abbreviations: ICU=intensive care unit; KPNC=Kaiser Permanente Northern California; KPNW=Kaiser Permanente Northwest; NA = not applicable; SMD=standardized mean or proportion difference; VISION=Virtual SARS-CoV-2, Influenza, and Other respiratory viruses Network. * Patient received a positive SARS-CoV-2 test result using a molecular test and received a negative or indeterminate test result or had an unknown test result for both respiratory syncytial virus and influenza. Patient received a negative SARS-CoV-2 test result using a molecular test and received a negative influenza test result or had an unknown influenza test result. A larger SMD indicates a larger difference in variable distributions between hospitalizations for vaccinated versus unvaccinated patients, or for patients who received a positive SARS-CoV-2 test result versus patients who received a negative SARS-CoV-2 test result. For mRNA COVID-19 vaccination status, a single SMD was calculated by averaging the absolute SMDs obtained from pairwise comparisons of each vaccinated category versus unvaccinated. Specifically, SMD was calculated as the average of the absolute value of the SMDs for 1) updated dose, 759 days earlier versus no updated dose; and 2) updated dose, 60119 days earlier versus no updated dose. The no updated dose group included all eligible persons who did not receive an updated COVID-19 vaccine dose, regardless of number of previous (i.e., original monovalent and bivalent) doses (if any) received. ** Date ranges of hospitalizations by site: HealthPartners (September 21, 2023February 17, 2024), Intermountain Health (September 21, 2023February 17, 2024), KPNC (September 21, 2023February 17, 2024), KPNW (September 21, 2023February 17, 2024), Regenstrief Institute (September 21, 2023February 13, 2024), and University of Colorado (September 21, 2023February 4, 2024). Other, non-Hispanic race persons reporting non-Hispanic ethnicity and any of the following options for race: American Indian or Alaska Native, Asian, Native Hawaiian or other Pacific Islander, other races not listed, and multiple races; because of small numbers, these categories were combined. Unknown includes persons with missing race and ethnicity in their electronic health records. Underlying condition categories included pulmonary, cardiovascular, cerebrovascular, musculoskeletal, neurologic, hematologic, endocrine, renal, and gastrointestinal. All persons in the analysis had one or more immunocompromising condition. *** Chronic respiratory condition was defined using International Classification of Diseases, Tenth Revision discharge codes for asthma, chronic obstructive pulmonary disease, cystic fibrosis, or other lung disease. Persons included in the analysis might have one or more immunocompromising conditions; therefore, column totals might add to more than 100%. In-hospital death was defined as death while hospitalized within 28 days after admission. The JN.1 predominant period was considered to have started December 24, 2023.

Abbreviations: Ref=referent group; VE=vaccine effectiveness; VISION=Virtual SARS-CoV-2, Influenza, and Other respiratory viruses Network. * VE was calculated as (1 odds ratio) 100%, with odds ratios calculated using logistic regression. The odds ratio was adjusted for age, sex, race and ethnicity, geographic region, and calendar time (days since January 1, 2021). The no updated dose group included all eligible persons who did not receive an updated COVID-19 vaccine dose, regardless of number of previous (i.e., original monovalent and bivalent) doses (if any) received.

Suggested citation for this article: Link-Gelles R, Rowley EA, DeSilva MB, et al. Interim Effectiveness of Updated 20232024 (Monovalent XBB.1.5) COVID-19 Vaccines Against COVID-19Associated Hospitalization Among Adults Aged 18 Years with Immunocompromising Conditions VISION Network, September 2023February 2024. MMWR Morb Mortal Wkly Rep 2024;73:271276. DOI: http://dx.doi.org/10.15585/mmwr.mm7312a5.

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Interim Effectiveness of Updated 20232024 (Monovalent XBB.1.5) COVID-19 Vaccines Against COVID-19Associated ... - CDC