On October 19, the Advisory Committee on Immunization Practices (ACIP) met, and, among other vaccine issues, they discussed the rise of COVID-19 disease incidence in infants younger than 6 months of age and the effectiveness of maternal COVID-19 vaccination in pregnant people and infants. They also reviewed COVID-19 vaccines in children. Here are some highlights.

COVID-19 during pregnancy and in the months after birth, but before age of vaccination

COVID-19 vaccination is important to protect women and their unborn babies during pregnancy and to protect their babies in the months after birth before they can be vaccinated.

As demonstrated in the meta-analysis by Allotey and colleagues and the study by Neelam and colleagues, analyzing data from the Surveillance for Emerging Threats to Mothers and Babies Network, COVID-19 infection during pregnancy can result in untoward outcomes:

  • SARS-CoV-2 infection during pregnancy makes people more likely to suffer complications (e.g., mortality, intensive care unit admission, invasive ventilation).
  • Compared with pregnant women without COVID-19, those with the disease were more likely to experience unfavorable perinatal outcomes (e.g., preterm birth and stillbirth).

COVID-19 vaccination of moms is also important for their babies:

  • Allotey and colleagues found increased likelihood of admission to the neonatal intensive care unit for babies born to mothers with COVID-19 versus those without COVID -19.
  • Infants too young to receive COVID-19 vaccine (i.e., those 0 to 5 months of age) had the second highest rate of COVID-19-associated hospitalization during the Omicron phase of the pandemic.

The good news is that maternal vaccination against COVID-19 has been shown to protect both pregnant people and their newborns in the months after birth before vaccination, including from severe disease and hospitalization. Importantly, vaccine effectiveness was lower when there was a mismatch between the vaccine and predominant circulating variant, such as when using original monovalent mRNA vaccines during the Omicron phase of the pandemic; however, vaccine efficacy increased when the second dose was given after, compared with before, 20 weeks gestation.

Rates of COVID-19 vaccination of children

Although we know that children can become severely ill or die from COVID-19, the comparatively low rates of severe illness compared with older adults and lingering misconceptions about frequency of infection and vaccine safety among children have led some parents to opt out of COVID-19 vaccination for their children. In addition, vaccine uptake varies among age groups of children depending on how long the recommendation for each group has been in effect. As of October 12, 2022:

  • About 6.9% of children 6 months to 4 years of age have received a single dose.
  • About 38.6% of children 5 to 11 years of age have received one dose, and 15.6% completed the primary series.
  • About 71.1% of those 12 to 17 years of age have received one dose, and 29.3% completed the primary series.

Technical considerations when vaccinating children and adolescents

Because COVID-19 vaccination recommendations for different age groups have evolved over time and the products for some vary, it is easy to confuse details. Herein are a few key technical aspects of COVID-19 vaccine administration to keep in mind when immunizing children:

Packaging and dosage

The key to using the appropriate vaccine for each age group relies on checking the color coding:

6 months to 4 or 5 years of age

  • Upper age limit depends on product — Pfizer is used up to 4 years of age; Moderna is used up to 5 years of age.
  • Pfizer — Maroon cap; contains 3 micrograms per dose.
  • Moderna — Dark blue cap with magenta (bright pink) label border; contains 25 micrograms per dose.
  • Currently, no booster recommendations are in place for those younger than 5 years of age.

5 or 6 to 11 years of age

  • Lower age limit depends on product — Pfizer is used starting at 5 years of age; Moderna is used starting at 6 years of age.
  • Pfizer (primary) — Orange cap; contains 10 micrograms per dose.
  • Moderna (primary) — Dark blue cap with purple label border; contains 50 micrograms per dose.
  • Booster dosing begins at 5 years of age. Only bivalent products can be used for booster doses.
  • Pfizer (bivalent booster) — Orange cap; contains 10 micrograms per dose.
  • Moderna (bivalent booster) — Dark blue with gray label border; contains 25 micrograms in 0.25 milliliter per dose.

12 years and older

  • Pfizer (primary) — Gray cap; contains 30 micrograms per dose.
  • Moderna (primary) — Red cap with light blue label border; contains 100 micrograms per dose.
  • Pfizer (bivalent booster) — Gray cap; contains 30 micrograms per dose.
  • Moderna (bivalent booster) — Dark blue cap with gray label border; contains 50 micrograms in 0.5 milliliter per dose.

Vaccines for the primary series should be the same per individual, but booster dose brand can vary from that of the primary series.

Transitioning to a new age group

Questions may arise when a child has a birthday that causes them to transition to a different age group during their completion of the primary series. The CDC offers guidance for this scenario.

Turning 5 during receipt of the primary series with Pfizer vaccine

Turning 6 during receipt of the primary series with Moderna vaccine

Turning 12 during receipt of the primary series

  • The "recommended scenario" for either product is to use the age-recommended vaccine at the time of the dose.
  • "Acceptable scenarios" include using either dosage for either dose (within the same brand).
  • See the CDC guides, Pfizer | Moderna.

Incorrect vial labels

An important document offered by Immunize.org, “Checklist of Current Versions of U.S. COVID-19 Vaccination Guidance and Clinic Support Tools,” offers links to the most recent documents related to COVID-19 vaccine use. For example, the “Checklist” provides details on two labeling issues for vaccines authorized in June 2022:

To ensure that you have the latest version of the “Checklist,” visit Immunize.org’s COVID-19 resources page.

In sum

Much work is ahead as we seek to improve COVID-19 vaccination rates, deal with variants, and develop a long-term approach to COVID-19 vaccination. This effort is likely to generate updated recommendations and new questions, but many groups are working to organize the information and serve as resources for you and your team. Hopefully, this article helps you locate some of them.

Data and meeting sources

Additional resources

Materials in this section are updated as new information and vaccines become available. The Vaccine Education Center staff regularly reviews materials for accuracy.

You should not consider the information in this site to be specific, professional medical advice for your personal health or for your family's personal health. You should not use it to replace any relationship with a physician or other qualified healthcare professional. For medical concerns, including decisions about vaccinations, medications and other treatments, you should always consult your physician or, in serious cases, seek immediate assistance from emergency personnel.