Following its 20-23 March meeting, WHO’s
Strategic Advisory Group of Experts on
Immunization (SAGE) revised the roadmap
for prioritizing the use of COVID-19 vaccines,
to reflect the impact of Omicron and high
population-level immunity due to infection
and vaccination.
The roadmap continues SAGE’s prioritization
of protecting populations at the greatest risk
of death and severe disease from SARS-CoV-2
infection and its focus on maintaining resilient
health systems. The roadmap newly considers
the cost-effectiveness of COVID-19 vaccination
for those at lower risk – namely healthy children
and adolescents – compared to other health
interventions.
The roadmap also includes revised recommenda-
tions on additional booster doses and the spacing
of boosters.
The current COVID-19 vaccines’ reduction of post-
COVID conditions is also considered but
the evidence on the extent of their impact is
inconsistent.
“Updated to reflect that much of the population is
either vaccinated or previously infected with COVID-
19, or both, the revised roadmap reemphasizes the
importance of vaccinating those still at-risk of severe
disease, mostly older adults and those with underlying
conditions, including with additional boosters,” stated
SAGE Chair Dr Hanna Nohynek. “Countries should
consider their specific context in deciding whether to
continue vaccinating low risk groups, like healthy child-
ren and adolescents, while not compromising the routine
vaccines that are so crucial for the health and well-being
of this age group.”
The revised roadmap outlines three priority-use groups
for COVID-19 vaccination: high, medium, and low.
These priority groups are principally based on risk of
severe disease and death, and consider vaccine
performance, cost-effectiveness, programmatic factors
and community acceptance.
The high priority group includes older adults; younger
adults with significant comorbidities (e.g. diabetes and
heart disease); people with immunocompromising
conditions (e.g. people living with HIV and transplant
recipients), including children aged 6 months and older;
pregnant persons; and frontline health workers.
For the high priority group, SAGE recommends an addi-
tional booster of either 6 or 12 months after the last
dose, with the timeframe depending on factors such as
age and immunocompromising conditions. All the
COVID-19 vaccine recommendations are time-limited,
applying for the current epidemiological scenario only,
and so the additional booster recommendations should
not be seen as for continued annual COVID-19 vaccine
boosters. The aim is to serve countries planning for the
near- to mid-term.
The medium priority group includes healthy adults –
usually under the age of 50-60 – without comorbidities
and children and adolescents with comorbidities.
SAGE recommends primary series and first booster
doses for the medium priority group.
Although additional boosters are safe for this group,
SAGE does not routinely recommend them, given the
comparatively low public health returns.
The low priority group includes healthy children and
adolescents aged 6 months to 17 years. Primary and
booster doses are safe and effective in children and
adolescents. However, considering the low burden of
disease, SAGE urges countries considering vaccination
of this age group to base their decisions on contextual
factors, such as the disease burden, cost effectiveness,
and other health or programmatic priorities and
opportunity costs.
The public health impact of vaccinating healthy children
and adolescents is comparatively much lower than the
established benefits of traditional essential vaccines for
children – such as the rotavirus, measles, and
pneumococcal conjugate vaccines – and of COVID-19
vaccines for high and medium priority groups.
Children with immunocompromising conditions and
comorbidities do face a higher risk of severe COVID-19,
so are included in the high and medium priority groups
respectively.
Though low overall, the burden of severe COVID-19 in
infants under 6 months is still higher than in children
aged 6 months to 5 years.
Vaccinating pregnant persons – including with an addi-
tional dose if more than 6 months have passed since
the last dose – protects both them and the fetus, while
helping to reduce the likelihood of hospitalization of
infants for COVID-19.
Countries that already have a policy in place for addi-
tional boosters should assess the evolving need based
on national disease burden, cost effectiveness and
opportunity costs.
Separate to the roadmap, SAGE also updated their
recommendations on bivalent COVID-19 vaccines,
now recommending that countries can consider using
BA.5 bivalent mRNA vaccine for the primary series.