Coronavirus Disease 2019 (COVID-19) Vaccination and Booster Dose Guidance

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AFL 21-42 From the California Department of Public Health

November 12, 2021

TO: Skilled Nursing Facilities (SNF)
SUBJECT: Coronavirus Disease 2019 (COVID-19) Vaccination and Booster Dose Guidance

All Facilities Letter (AFL) Summary

This AFL ensures SNF are aware of U.S. Food and Drug Administration (FDA) authorization and Centers for Disease Control and Prevention (CDC) recommendations for COVID-19 vaccine additional and booster doses, explains eligibility considerations for residents and healthcare personnel (HCP), and provides information and resources for facilities to provide or coordinate access to additional and booster doses for their residents.


During the late-summer Delta SARS-CoV-2 variant surge, California SNFs with high COVID-19 vaccination coverage experienced proportionately fewer cases and outbreaks compared with prior surges before vaccines were available. However, recent increases in SNF COVID-19 cases and several large outbreaks among SNF residents who completed their primary COVID-19 vaccine series in January–February may reflect waning immunity from the primary series, highlighting an urgent need for COVID-19 vaccine boosters in this population.

The purpose of this AFL is to ensure SNFs are aware of U.S. Food and Drug Administration (FDA) authorization and Centers for Disease Control and Prevention (CDC) recommendations for COVID-19 vaccine booster doses, explain eligibility considerations for SNF residents and HCP, and provide information and resources for SNFs to provide or coordinate access to additional and booster doses for their residents.

COVID-19 Vaccine Additional Dose Recommendations for Individuals with Moderate to Severe Immunocompromise

CDC recommends that individuals with moderately to severely compromised immune systems who received primary Pfizer-BioNTech or Moderna vaccine series should receive an additional dose of COVID-19 vaccine at least 28 days after their primary mRNA vaccine series. This recommendation applies to Pfizer-BioNTech recipients aged ≥12 years and Moderna recipients aged ≥18 years. People with moderately to severely compromised immune systems are especially vulnerable to COVID-19, and may not build the same level of immunity to 2-dose mRNA vaccine series compared to people who are not immunocompromised. This additional dose is intended to improve immunocompromised people’s response to their initial vaccine series.

After receiving a third mRNA vaccine dose, these immunocompromised individuals aged ≥18 years may receive a single COVID-19 booster dose (Pfizer-BioNTech, Moderna, or Janssen) at least 6 months after completing their third mRNA vaccine dose. In such situations, people who are moderately and severely immunocompromised may receive a total of four COVID-19 vaccine doses.

Moderately and severely immunocompromised people aged ≥18 years who received a single dose Janssen COVID-19 vaccine primary series should receive a single COVID-19 booster vaccine (Pfizer-BioNTech, Moderna or Janssen) at least 2 months (8 weeks) after receiving their initial Janssen primary dose.

COVID-19 Vaccine Booster Recommendations

Eligibility for COVID-19 Vaccine Booster Doses

Vaccine Booster TypeEligibility
Pfizer-BioNTech and ModernaPeople 65 years and olderResidents age 18+ who live in long-term care settings.  This includes SNF residentsPeople age 18-64 who:have underlying medical conditions;are at increased risk due to social inequity; orwork or live in high-risk settingswhich includes SNF HCP
Janssen (Johnson & Johnson)People age 18+.  This includes SNF residents and SNF HCP.

For Residents:

All long-term care residents, including SNF residents, aged ≥18 years should get a booster vaccine. Because residents in long-term care settings live closely together in group settings and are often older adults with underlying medical conditions, they are at increased risk of infection and severe illness from COVID-19.

Pfizer-BioNTech and Moderna vaccine recipients are eligible for a booster vaccine at least 6 months after completing their initial series.

Janssen (J & J) vaccine recipients are eligible at least 2 months after receiving their initial vaccination.

For HCP:

All SNF HCP are eligible for booster vaccines due to risk of workplace exposure. SNF HCP may be at increased risk of being exposed to COVID-19, which could be spreading where they work or reside. For Pfizer-BioNTech and Moderna vaccine recipients, all adults 65 years, and older and adults ages 50–64 years with underlying medical conditions or at increased risk due to social inequity should get a booster vaccine. The risk of severe illness from COVID-19 increases with age and can also increase for adults of any age with underlying medical conditions. In addition, CDC recommends that congregate care (including SNF) HCP ages 18–64 years may get a booster vaccine based on individual risks and benefits.

Pfizer-BioNTech and Moderna vaccine recipients are eligible for a booster vaccine at least 6 months after completing their initial series.

All Janssen (J & J) vaccine recipients are eligible at least 2 months after receiving their initial vaccination.

Selecting Which Booster Dose to Receive

People have the option to receive any of the FDA-approved or FDA-authorized COVID-19 booster products (Pfizer-BioNTech, Moderna, or Janssen), regardless of which product they received for their primary series. (Note: the Moderna booster dose is half of the dose for the primary series.) People may consider the benefits and risks of each product and discuss with their healthcare provider which product is most appropriate for them. The frequency and type of side effects after a booster dose are generally similar to those experienced after a primary series.  Providers may refer to the clinical guidance section “Considerations for use of Covid-19 Booster Dose” for more information.

Co-administration with Influenza Vaccine

COVID-19 vaccines can be given during the same visit with other vaccines, including flu vaccine, if the recipient is eligible for the vaccines. When deciding whether to administer another vaccine(s) with a COVID-19 vaccine, vaccination providers should consider whether the patient is behind or at risk of becoming behind on recommended vaccines, their risk of vaccine-preventable disease (e.g., during an outbreak or occupational exposures), and the reactogenicity profile of the vaccines.

If multiple vaccines are administered at a single visit, administer each injection at a different injection site. For adolescents and adults, the deltoid muscle can be used for more than one intramuscular injection administered at different sites in the muscle.

Best practices for multiple injections include:

  • Label each syringe with the name and the dosage (amount) of the vaccine, lot number, the initials of the preparer, and the exact beyond-use time, if applicable.
  • Separate injection sites by 1 inch or more, if possible.
  • Administer the COVID-19 vaccines and vaccines that may be more likely to cause a local reaction in different limbs, if possible.

Vaccine Safety Monitoring

The Vaccine Adverse Event Reporting System (VAERS) is a national early warning system to detect possible safety problems in U.S.-licensed vaccines. VAERS is co-managed by the Centers for Disease Control and Prevention (CDC) and the U.S. Food and Drug Administration (FDA). VAERS accepts and analyzes reports of adverse events (possible side effects) after a person has received a vaccination. 

Healthcare providers are required to report to VAERS the following adverse events after COVID-19 vaccination:

  • Vaccine administration errors, whether or not associated with an adverse event (AE)
  • Serious AEs regardless of causality. Serious AEs per FDA are defined as:
    • Death;
    • A life-threatening AE;
    • Inpatient hospitalization or prolongation of existing hospitalization;
    • A persistent or significant incapacity or substantial disruption of the ability to conduct normal life functions;
    • A congenital anomaly/birth defect;
    • An important medical event that based on appropriate medical judgment may jeopardize the individual and may require medical or surgical intervention to prevent one of the outcomes listed above
  • Cases of Multisystem Inflammatory Syndrome
  • Cases of COVID-19 that result in hospitalization or death

Healthcare providers are encouraged to report to VAERS any additional clinically significant AEs following vaccination, even if they are not sure if vaccination caused the event. More information available at the Vaccine Adverse Event Reporting System.

Options for Accessing and Providing COVID-19 Vaccines, including Booster Doses

Long-term Care Pharmacies:

SNF are encouraged to contact their regular/contract pharmacy to ask about COVID-19 vaccination, including booster doses. If you do not have a contracted pharmacy provider, there are participating Long-Term Care (LTC) pharmacies that may be available to service your facility’s COVID-19 vaccine needs. Facilities can directly contact a nearby LTC pharmacy of their choice to inquire and receive COVID-19 vaccine. A list of the participating LTC pharmacies in California can be found in the CDPH Long Term Care Facility (LTCF) COVID-19 Vaccine Toolkit (PDF), Appendix B.

Vaccination Appointments in Nearby Pharmacies or Healthcare Provider’s Offices:

SNF residents and HCP who are willing and able to travel to a vaccination site are encouraged to use vaccination sites in their local community (i.e., nearby pharmacies or healthcare provider’s office); this may be the fastest way to get vaccinated. There are multiple online resources to locate and schedule an appointment:

  • My Turn
    • Visit the My Turn website or, please call the CA COVID-19 Hotline at 1-833-422-4255 (Mon-Fri 8AM-8PM, Sat-Sun 8AM-5PM) for assistance
  • Vaccine Finder

On-site Vaccine Clinics from Retail Pharmacies:

Many retail pharmacies also offer on-site vaccine clinics (COVID and non-COVID vaccines) if certain requirements are met. Interested facilities can contact pharmacies directly to request an on-site vaccine clinic. Note that timing and availability of on-site clinics will vary based on facility details and pharmacy resources. Also note that flu vaccine and COVID-19 vaccine can be co-administered when planning these clinics. A list of the retail pharmacies, contact information, and clinic requirements can be found in the CDPH Long Term Care Facility (LTCF) COVID-19 Vaccine Toolkit (PDF).

Becoming a Vaccine Provider:

SNFs with the ability to accept, store, administer and report COVID-19 vaccine administration can directly enroll with the state myCAvax system to become COVID-19 vaccine providers. Please refer to myCAvax Systems Overview (PDF) and Steps to Enrollment for details on how to become a COVID-19 vaccine provider. 

ne provider.

Local Health Department (LHD) Resources

If you are having difficulties arranging COVID-19 vaccination with the pharmacies or other vaccine providers, please contact your LHD for assistance. There are LHDs who may have local resources (i.e., mobile strike team, in-home vaccination service, transportation service) available to assist LTCFs.

State Resources

If facilities still have difficulties and are unable to arrange COVID-19 vaccination from any of the above resources, please contact the state call center for support

Federal Resources

If local and state resources are unable to connect your facility to COVID-19 vaccination, CDC can also support: Options for Coordinating Access to COVID-19 Vaccines.

How to Access Vaccines


If you have any questions about infection control concerns, please contact the CDPH Healthcare-Associated Infections Program at or


Original signed by Cassie Dunham

Cassie Dunham

Acting Deputy Director

Additional Resources and Links

Booster vaccine clinical info: