The COVID-19 pandemic has changed in recent months with the emergence of the more transmissible Delta variant taking over as the dominant strain throughout the country. The number of daily infections, though still about 1/3 of January peak continue to rise. This wave of infection has been particularly hard on the unvaccinated, accounting for over 90% of COVID related infections.

Despite the indisputable evidence of the effectiveness of the COVID vaccines in preventing serious infection and death, there have been several studies in patients who are immunocompromised showing a decreased response to vaccination with two doses both the Pfizer and Moderna mRNA Vaccines. 40-44% of vaccinated patients who are hospitalized with COVID infection are immunocompromised.

“Immunocompromised” is a relative term and there is a wide range of decreased immune system function dependent on the cause of the immune compromise. Studies have shown a significant decrease in vaccine effectiveness in certain groups of immunocompromised patients to achieve adequate antibody protection. Mainly patients taking medications for solid organ transplant and cancer. Patients taking less potent immune suppressing medications like Anti TNF biologics or direct acting immune suppressive or on hemodialysis have also shown a good but still decreased ability to develop a full antibody response when compared to a control group of patients who are not immune suppressed. Additional studies in patients without an adequate antibody response, a third dose allowed them to “convert” to an adequate response 40-70% of the time. These studies also have not shown any significant addition risk of harm over those receiving 2 doses.

For this reason, the FDA and CDC have announced an amendment to the Emergency Use Authorization (EUA) for the Pfizer and Moderna mRNA vaccines. This amendment authorizes a third shot at least 28 days after the second shot for individuals with certain immunocompromised conditions. The recommendation is to try and use the same brand as your first two shots but if that is unavailable then crossover is allowed. This recommendation does not apply to the single shot recombinant vaccine manufactured by Johnson and Johnson.

We are writing to you because many of our patients who have received a liver transplant , treatment for a GI or liver cancer or have Inflammatory Bowel Disease (IBD) would benefit from a third dose. USDH physicians agree with the FDA’s recommendations that the following patients should seek a 3rd dose of vaccine.  All patients who were taking the following medications or receiving the following treatments within a month of receiving one or both of the Pfizer or Moderna vaccine doses.

The conditions and medications list for which a 3rd dose is recommended is as follows:

  • Corticosteroids
  • Active or recent treatment for cancer or organ transplant
  • Direct acting immune suppressants like Xeljanz, methotrexate, 6MP or Imuran

–     Biologic medications like Remicade, Inflectra, Renflexis, Avsola, Cimzia, Simponi, Humira,   Stelara, or Entyvio

We also recommend that all cancer treatment and liver transplant patients also check with their oncologist or transplant center for their recommendations regarding receiving a third dose and follow the recommendations of these experts.

Again, patients are recommended to receive same brand of first 2 doses whenever possible and 3rd doses are recommended at least 28 days following dose


  1. FDA Emergency Use Authorization Amendment (EUA) for Pfizer- BioNTech (NNT162b2) and Moderna Covid 19 Vaccine (mRNA 1273). Published 12 AUG 2021
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