Latest Guidance Updates
03 May 2023: major update to align with the revised Green Book chapter 14a recommendations for the spring 2023 vaccination campaign, and new information on the introduction of a primary immunisation for children aged 6 months to 4 years at higher risk.
This Guidelines summary provides information to those who will be involved in the COVID-19 national vaccination programme. It includes recommendations on the current vaccines, eligibility, administration, doses, and schedules.
The information in this guidance was correct at time of publication. As COVID-19 is an evolving disease, some of the information may change. Updates will be made to this document as new information becomes available. You are therefore advised to consult the online version of the full guidance to ensure you are accessing the latest information.
This Guidelines summary excludes some information from the full guideline. For the complete set of recommendations, refer to the full guideline.
Reflection on your Learnings
Reflection is important for continuous learning and development, and a critical part of the revalidation process for UK healthcare professionals. Click here to access the Guidelines Reflection Record.
The 'Living with COVID-19' Programme
- During 2023, the primary course of vaccination will become a targeted offer available only to those at higher risk of severe COVID-19 and only during the planned seasonal booster campaigns
- Exceptionally, based on clinical judgement, individuals who develop severe immunosuppression may be at high risk of severe COVID-19 and less able to sustain any protection from previous vaccination or exposure, and should be considered for catch-up primary vaccination or additional dose(s) of vaccination before the next seasonal campaign.
COVID-19 Vaccination Eligibility
- All staff involved in delivering the programme need to understand who is eligible to receive COVID-19 vaccination, which vaccine they should receive, and the reasons why
- Full details on vaccine eligibility, with detail of the at-risk conditions, are included in the Green Book COVID-19 chapter and have therefore not been detailed in this guidance.
- As each vaccine is presented, stored, and prepared differently, immunisers must ensure they are familiar with the specific details of the vaccine with which they are working
- The following COVID-19 vaccines are both licensed and currently supplied for use in the UK national COVID-19 vaccination programme.
Pfizer BioNTech Comirnaty COVID-19 Vaccines
- Comirnaty bivalent Original/Omicron BA.4–5 (15/15 mcg)/dose is the ‘adult/adolescent’ Comirnaty vaccine. It’s a bivalent vaccine licensed and recommended for primary and booster doses for eligible individuals aged 12 years and above. It is also referred to in this guidance as Comirnaty bivalent BA.4–5 15/15. Comirnaty bivalent Original/Omicron BA.1 (15/15 mcg)/dose may alternatively be supplied
- Comirnaty 10 mcg/dose is the ‘paediatric’ Comirnaty vaccine. It is a monovalent vaccine licensed and recommended for primary and booster doses for eligible individuals from 5–11 years of age, and for completing primary doses for eligible individuals aged 12 years old who commenced primary vaccination when aged 11. It is also referred to in this guidance as Comirnaty 10 Concentrate
- Comirnaty 3 mcg/dose is the ‘infant/pre-school children’s’ Comirnaty vaccine. It is a monovalent vaccine licensed for primary doses for eligible individuals from 6 months to 4 years of age. In certain circumstances, it may be administered as a primary dose to children aged 5 years old. It is also referred to in this document as Comirnaty 3 Concentrate.
Moderna Spikevax COVID-19 Vaccines
- Spikevax bivalent Original/Omicron BA.4–5 (25/25 mcg)/dose is licensed for booster doses for individuals aged 12 years and above, but is recommended for primary and booster doses only for eligible individuals aged 18 years and above. It is also referred to in this guidance as Spikevax bivalent BA.4–5 25/25. Spikevax bivalent Original/Omicron BA.1 (25/25 mcg)/dose may alternatively be supplied.
Novavax COVID-19 Vaccine
- Nuvaxovid is a monovalent recombinant, adjuvanted vaccine licensed for primary doses from age 12 years and for booster doses from age 18 years, but may be used for boosting from age 12 years. It is available at selected sites to individuals for whom an mRNA vaccine is clinically unsuitable (only).
Sanofi COVID-19 Vaccine
- VidPrevtyn Beta is a monovalent recombinant adjuvanted vaccine licensed for booster doses for individuals aged 18 years and above. It is recommended for booster doses for eligible individuals aged 75 years and above and, in defined operational circumstances, for some eligible individuals aged 65 years and above and for primary doses from that age.
Other Licensed Vaccines
- The following vaccine is licensed by the Medicines and Healthcare products Regulatory Agency (MHRA), but not currently being supplied:
- Pfizer BioNTech Comirnaty bivalent Original/Omicron BA.4–5 (5/5 mcg)/dose licensed for 5–11 years of age
- The following vaccines are no longer being supplied:
- Vaxevria (AstraZeneca)
- Comirnaty 30 Concentrate (Pfizer BioNTech)
- Spikevax Original (Moderna)
- All the currently UK-authorised vaccines in use are supplied in multidose vials.
Vaccine Indications and Schedules—Primary Doses
Individuals Aged 5 Years and Above
- Anyone who is eligible for a spring 2023 booster dose, but has not yet commenced or completed a primary course, should first receive their outstanding primary dose(s)
- The 'evergreen' offer of primary immunisation remains in place during the spring 2023 campaign for all individuals aged 5 years and above who have yet to start or complete a primary course, including those in a clinical risk group from their 5th birthday. Note, however, that healthy children aged 5 (not in any clinical risk group) are only eligible if their 5th birthday occurred on or before 31st August 2022
- The offer of primary immunisation is expected to cease at the end of this campaign for healthy individuals, whereas those in clinical risk groups (except those who are severely immunosuppressed) will not be able to receive any outstanding primary doses until the next seasonal campaign.
Third Primary Doses for Those Aged 6 Months and Over with Severe Immunosuppression
- Individuals aged 6 months and above who were severely immunosuppressed at or around the time of their primary immunisation should be offered an age-appropriate third primary dose a minimum of 8 weeks after receiving their second dose.
Vaccines for Primary Doses
- For adults, the Comirnaty bivalent Original/Omicron 15/15 and Spikevax bivalent Original/Omicron 25/25 mRNA COVID-19 vaccines are now recommended, off label, for all primary doses. The Sanofi Pasteur COVID-19 vaccine VidPrevtyn Beta may be used off label as a primary dose in those aged 65 years and over if there would otherwise be a delay in vaccination and when an mRNA vaccine is clinically unsuitable
- For young people aged 12 years and above (but not yet 18 years of age) only the Pfizer BioNTech Comirnaty bivalent Original/Omicron 15/15 mRNA COVID-19 vaccines may be used. Comirnaty 10 mcg/dose is recommended for all 5–11-year-olds and for 12-year-olds who, having commenced primary immunisation with this vaccine, had their 12th birthday between doses
- Comirnaty 3 mcg/dose is licensed for primary doses for eligible individuals from 6 months to 4 years of age. Children below 6 years of age, including those who commenced immunisation with the 3 mcg infant dose before turning 5, may commence and complete primary vaccination with the 3 mcg/dose vaccine if that is the only vaccine readily available in the clinic
- Nuvaxovid is licensed for primary doses from age 12 years and may be used for individuals in whom an mRNA vaccine is clinically unsuitable. Once Nuvaxovid is no longer being supplied, an individual clinical judgement will be required regarding vaccination of individuals under 65 years of age for whom an mRNA vaccine is clinically unsuitable; expert advice should be obtained and, if a decision is made to administer an mRNA vaccine, it should be given in hospital under medical supervision
- Vaccination of those aged 6 months to 11 years in whom mRNA vaccines are unsuitable requires an individual clinical judgement.
- There is evidence of a better immune response and/or protection when longer intervals between doses in the primary schedule are used
- The Joint Committee on Vaccination and Immunisation (JCVI) is therefore currently recommending an interval of 8 weeks between doses of all the available COVID-19 vaccines when a two-dose primary schedule is used for adults and children from aged 6 months at high risk
- Although Comirnaty 3 mcg/dose is licensed as a three-dose primary course, the JCVI has recommended a two-dose schedule for eligible children aged 6 months to 4 years of age. The minimum interval is 8 weeks
- The main exception to the 8-week lower interval is for those about to commence immunosuppressive treatment. In these individuals, the minimal intervals (21 days for Pfizer BioNTech or Novavax vaccines or 28 days for Moderna Spikevax vaccines) may be followed to ensure that the vaccine is given while their immune system is better able to respond.
Individuals Commencing Their Primary Course During the Present Vaccination Campaign
- Many eligible individuals who receive their first primary dose 8 weeks or less before the end of the present campaign will not be able to complete their primary course before this campaign ends. The only exceptions are individuals about to start immunosuppressive therapy who may be considered for a second dose at a shorter interval and those who develop severe immunosuppression who may be considered for an additional dose of vaccination between seasonal campaigns
- Unvaccinated individuals who are eligible for a booster should be encouraged to receive their first dose during the campaign. Clinicians should, as part of the consent process, explain why they do not need a second dose at this time
- Individuals in a clinical risk group may be able to receive a second dose with the latest recommended vaccine during the next campaign if they remain eligible.
Previous Incomplete Vaccination
- If the vaccine course is interrupted or delayed, it should be resumed preferably using the same vaccine, but any previous primary dose(s) should not be repeated.
Circumstances in Which Different Vaccines may be Given for the First and Second Primary Doses
- Accumulating evidence now supports the use of heterologous schedules for primary immunisation and any mRNA vaccine can be used to complete a primary course. For individuals who started the schedule and who attend for vaccination when the same vaccine is not available or suitable, or if the first product received is unknown or not available, one dose of the locally available product should be given to complete the primary course
- Individuals who experienced severe expected reactions after a first dose of AstraZeneca or Pfizer BioNTech vaccines should be informed about the higher rate of such reactions when they receive a second dose of an alternate vaccine
- Children aged 5–12 years who have commenced immunisation with the paediatric dose of Pfizer BioNTech Comirnaty 10 mcg/dose vaccine should ideally complete vaccination with the paediatric dose, but an adult/adolescent dose of a Comirnaty bivalent 15/15 mcg/dose vaccine is an alternative in those who turn 12 years of age between doses. Those who present for the second dose over the age of 12 years should be given an adult/adolescent dose of vaccine
- Children below 6 years of age, including those who commenced immunisation with the infant dose of Pfizer BioNTech Comirnaty 3 mcg/dose vaccine before turning 5, may commence and complete primary vaccination with the 3 mcg product if that is the only vaccine readily available in the clinic.
Vaccine Indications and Schedules—Booster Doses
- The JCVI has recommended that a booster dose should be given to:
- adults aged 75 years and over
- residents in a care home for older adults
- individuals aged 5 years and over who are immunosuppressed.
Limits to Vaccination Offers and 'Missed' Booster Doses
- Booster doses offer time-limited protection (protection increases after each dose, but then wanes over the following few months). Individuals who have not taken up the offer of additional doses therefore cannot be ‘caught-up’, as the dose(s) they missed were intended to protect them during a period of time that has now elapsed. If eligible, they should be vaccinated during the current campaign and encouraged to take up any future offers that apply.
Vaccines Used for Spring 2023 Booster Doses
- The bivalent mRNA COVID-19 vaccines are licensed for boosting. The Pfizer BioNTech Comirnaty bivalent Original/Omicron 15/15 vaccines may be given to anyone aged 12 years and above. The Moderna Spikevax bivalent Original/Omicron 25/25 vaccines may be given to anyone aged 18 years and above
- Sanofi COVID-19 vaccine VidPrevtyn Beta is an additional option for those aged 75 years and above. It is anticipated that the inclusion of an adjuvant in this vaccine will strengthen the immune response in these older individuals, who are at greatest risk of serious illness if they have a COVID-19 infection. In defined operational circumstances, this vaccine may also be administered to some eligible individuals aged 65 years and above
- Nuvaxovid is licensed for booster doses from aged 18 years, but is recommended from age 12 years as a booster dose when an mRNA vaccine is clinically unsuitable (contraindicated)
- Comirnaty 10 mcg/dose is licensed for boosting for individuals aged 5–11 years. Vaccination of those aged 5–11 years in whom mRNA vaccines are unsuitable requires an individual clinical judgement
- Timeliness of vaccination is more important than the type of booster vaccine used. For those aged 12 and above, if the age-appropriate bivalent mRNA vaccine containing the latest variant (currently Omicron BA.4–5) is not available, a bivalent with a previous variant (such as Omicron BA.1) may be used if there would otherwise be a delay in vaccination.
Unknown Vaccination History
- If the primary immunisation history of an individual eligible for a booster dose during the spring 2023 is unknown, it is preferable, rather than delay vaccination, to administer a dose of any suitable vaccine
- If upon further investigation this is discovered to have been their first primary dose, then a second dose can be given, within the same vaccination campaign, after a minimum 8-week interval. If the campaign ends before these 8 weeks have elapsed and they remain eligible, they can receive this dose during the next campaign
- If they are severely immunosuppressed, clinical judgement should be used to determine the timing of this second dose, which may, if necessary, be administered between campaigns.
Specific Population GroupsFor more information on immunosuppression, refer to the full guideline.
- COVID-19 vaccines can be given to pregnant women
- Vaccination against COVID-19 can take place at the same time as, or at any interval before or after, other vaccines offered in pregnancy (pertussis, influenza)
- During the spring 2023 campaign, pregnant women may be offered primary vaccination as part of the ‘evergreen’ offer, as this remains in place for everyone already eligible who has yet to start or complete a primary course
- Pregnant women who have already received a dose of AstraZeneca or Moderna vaccine can complete with any mRNA vaccine (provided there are no contraindications)
- If a woman finds out she is pregnant after she has started a course of COVID-19 vaccine, she should complete vaccination during pregnancy using the same vaccine product (unless contraindicated)
- Routine questioning about last menstrual period and/or pregnancy testing is not required before offering the COVID-19 vaccine. Eligible women who are planning pregnancy or are in the immediate postpartum can be vaccinated.
- COVID-19 vaccines can be given to eligible breastfeeding women
- Those eligible for the spring 2023 campaign are women who require a primary dose as part of the ‘evergreen’ offer, or who are immunosuppressed and require a spring 2023 booster dose
- There is no known risk associated with giving non-live vaccines while breastfeeding. The JCVI advises that eligible breastfeeding women should be offered vaccination with any suitable COVID-19 vaccine.
Children and Young People
Interval Between Doses for 5–17 Year Olds who are Not in a Clinical Risk Group
- For those aged 5–17 who are not in a high-risk group, a 12-week interval is preferred, but an 8-week interval is acceptable and may be necessary for operational reasons or to complete the course during the campaign.
Administration of COVID-19 Vaccine
Infection Prevention and Control
- All those attending for vaccination and those delivering vaccination should wear appropriate personal protective equipment as described in the infection prevention and control advice current at the time of administering the vaccine. Wearing gloves is not recommended.
- COVID-19 vaccines should be administered by intramuscular injection, preferably into the densest part of the deltoid muscle of the upper arm
- Individuals who have minimal muscle mass in the deltoid area of the upper arm, or a particular reason to avoid immunisation in the deltoid muscle, can be given their vaccine in the vastus lateralis muscle in the thigh if necessary
- The area for injection should be clearly visible and accessible. Garments with long or tight sleeves may need to be removed. The injection site does not need to be cleaned unless visibly dirty. If cleaning is required, water should be used and the area dried with a gauze swab. It is not necessary to disinfect the skin
- Insert the needle into the injection site far enough to ensure it will deliver the vaccine into the muscle and depress the plunger. There is no need to pull back on the plunger (aspirate) before the plunger is depressed to release the vaccine into the muscle because there are no large blood vessels at the recommended injection sites
- Ensure the full dose is administered, as a partial dose may not evoke a full immune response. Remove the needle and if there is any visible blood at the injection site, the patient can apply pressure to the site with a piece of gauze or cotton wool.
Administering COVID-19 Vaccine to Individuals with a Bleeding Disorder
- Individuals with bleeding disorders may be vaccinated intramuscularly if, in the opinion of a doctor familiar with the individual's bleeding risk, vaccines or similar small volume intramuscular injections can be administered with reasonable safety by this route
- If the individual receives medication or treatment to reduce bleeding, for example, treatment for haemophilia, intramuscular vaccination can be scheduled shortly after such medication or treatment is administered
- A fine needle (23 or 25 gauge) should be used for the vaccination, followed by firm pressure applied to the site (without rubbing) for at least 2 minutes. The individual or carer should be informed about the risk of haematoma from the injection.
Period of Observation Following Immunisation with COVID-19 Vaccine
- Following COVID-19 vaccine administration, vaccinated individuals should be observed for any immediate reactions while they are receiving any verbal post-vaccination information (such as possible reactions and what, if anything, to do about these) and exiting the vaccination centre. They, or their parent/carer, should also be informed where they can obtain further advice if they require it following vaccination
- Patients with a personal history of allergy will require a period of observation following vaccination (either 15 or 30 minutes depending on their clinical history)
- As fainting can occur following vaccination, all those vaccinated with any of the COVID-19 vaccines should either be driven by someone else or should not drive for 15 minutes after vaccination.
Advice to Vaccine Recipients Following Immunisation with COVID-19 Vaccine
- Following COVID-19 vaccine administration, vaccine recipients should be given information about possible reactions to the vaccine (see adverse reactions section below), how to treat these, and when and from whom to seek further advice if required. Vaccinators should offer the manufacturer’s patient information leaflet for the vaccine that they have received and an age-appropriate UKHSA information leaflet in an accessible format.
- Commonly reported reactions following COVID-19 vaccination include:
- local reactions: injection site pain, redness and localised swelling; these usually occur and resolve within a few days of the injection
- systemic reactions: tiredness, headache, muscle aches, chills, joint pain, and a raised temperature (pyrexia); nausea or vomiting and axillary lymph gland swelling or tenderness are also reported. Symptoms are usually mild or moderate in intensity and resolve within a few days after vaccination
- Rates of reactions are higher in people when mixed (heterologous) vaccine schedules are received.
Reporting Adverse Reactions
- Suspected adverse reactions following administration of COVID-19 vaccine should be reported to the MHRA. Both vaccine recipients and healthcare providers can report any possible adverse reactions observed with these vaccines using the Yellow Card scheme
- Any adverse reaction to a vaccine should be documented in the individual’s record and the individual’s GP should be informed.
Contraindications and Precautions
- Relative contraindications to receiving a COVID-19 vaccine are:
- individuals who have had a previous systemic anaphylaxis reaction to a COVID-19 vaccine
- individuals with a prior allergic reaction to any component (excipient) of the COVID-19 vaccine, for example polyethylene glycol.
Minor Illness at Time Vaccination Due
- Minor illnesses without fever or systemic upset are not valid reasons to postpone immunisation. If an individual is acutely unwell, immunisation may be postponed until they have fully recovered. This is to avoid confusing the differential diagnosis of any acute illness (including COVID-19) by wrongly attributing any signs or symptoms of the illness as being possible reactions to the vaccine.
Co-Administration of COVID-19 Vaccine with Other Inactivated or Live Vaccines
- This is not a reason to defer any COVID-19 vaccination but should be taken into account when providing advice
- Based on the available evidence, therefore:
- when individuals in an eligible cohort present having recently received one or more vaccines, whether inactivated or live, COVID-19 vaccination should still be given
- the same applies for other live and inactivated vaccines when COVID-19 vaccination has been received first or where a patient presents requiring two or more vaccines.
For information on conditions including thrombosis and thrombocytopenia syndrome and capillary leak syndrome; vaccination of individuals with a current or previous history of COVID-19 disease or long COVID; treatments for COVID-19 disease; legal aspects of vaccine administration; inadvertent vaccine administration errors; and background to the COVID-19 vaccination programme, refer to the full guideline.