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State of California—Health and Human Services Agency
California Department of Public Health

AFL 21-20.2
June 14, 2023

General Acute Care Hospitals (GACHs)
Acute Psychiatric Hospitals (APHs)

Coronavirus Disease 2019 (COVID-19) Vaccine Recommendations for Eligible Individuals Prior to Discharge
(This AFL supersedes AFL 21-20.1)

​​​​​​​​This AFL has been superseded - please see AFL ​23-33​


All Facilities Letter (AFL) Summary​

This AFL recommends GACHs and APHs offer COVID-19 vaccinations to eligible individuals prior to discharge. This AFL provides technical assistance on options and resources to assist GACHs and APHs vaccinate their patients.​​


Ongoing morbidity and mortality from evolving variants of SARS-CoV-2 underscore the continued importance of COVID-19 vaccines and related measures, including testing and masking, to protect patients, staff, and the community from COVID-19.​

A recent CDC report showed that adults 65 years and older, especially those who are unvaccinated, continue to be at high risk of death from COVID-19. Adults 85 years and older are at highest risk, accounting for 40 percent of adults dying of COVID-19. To reduce the spread of COVID-19, CDPH recommends that prior to discharge from the hospital, 24-hour observation, or emergency department, GACHs and APHs offer COVID-19 vaccinations, including bivalent booster doses, to eligible patients, according to their past history of COVID vaccination especially those at highest risk of morbidity and mortality from COVID-19, such as:  

  • Patients age 65 years or older
  • Psychiatric patients
  • Patients being discharged to congregate care or residential settings, such as: post-acute medical facilities, skilled nursing facilities, residential care facilities for the elderly, correctional facilities, behavioral health facilities, and homeless shelters​

Overview of COVID-19 Vaccination

CDC clinical recommendations are summarized below. Refer to CDC Interim Clinical Considerations for Use of COVID-19 Vaccines for more details.

Pfizer-BioNTech COVID-19 Vaccine, Bivalent and Moderna COVID-19 Vaccine, Bivalent are authorized and recommended for use. All currently available mRNA COVID-19 vaccines in the United States are formulated as a bivalent vaccine based on the original (ancestral) strain of SARS-CoV-2 and the Omicron BA.4 and BA.5 (BA.4/BA.5) variants of SARS-CoV-2. Novavax COVID-19 Vaccine, Adjuvanted remains authorized for use as a 2-dose primary series and as a booster dose in certain limited situations.

The number of bivalent mRNA vaccine doses varies by age, vaccine, previous COVID-19 vaccines received, and the presence of moderate or severe immune compromise.​

CDC Guidance for People Who Are Not Immunocompromised  

For people who are not moderately or severely immunocompromised:

  • At the time of initial vaccination
    • Children ages 6 months–4 years are recommended to receive 2 or 3 bivalent mRNA vaccine doses
    • Children age 5 years are recommended to receive 1 or 2 bivalent mRNA vaccine doses
  • People ages 6 years and older who are unvaccinated or previously received only monovalent vaccine doses are recommended to receive 1 bivalent mRNA vaccine dose
  • People ages 65 years and older have the option to receive 1 additional bivalent mRNA vaccine dose​

CDC Guidance for People Who Are Immunocompromised

For people who are moderately or severely immunocompromised:

  • At the time of initial vaccination, people ages 6 months and older are recommended to receive 3 bivalent mRNA doses
  • People ages 6 months and older who previously received only monovalent doses are recommended to receive 1 or 2 bivalent mRNA vaccine doses, depending on age and vaccine product
  • People who previously received a bivalent mRNA vaccine dose(s) have the option to receive 1 or more additional bivalent mRNA doses

Please direct patients to consult their primary care provider or to the MyTurn or CDC Vaccines websites for assistance in obtaining future doses recommended beyond the dose administered before discharge at your hospital.

Hospitals interested in becoming a COVID-19 vaccine provider are directed to the California COVID-19 Vaccination Program website (myCAvax).

If you have any questions about COVID-19 vaccines, please contact the Provider COVID-19 Call Center by email at or by phone at (833) 502-1245 Monday – Friday from 8 AM–6 PM.



Original signed by Cassie Dunham

Cassie Dunham

Deputy Director


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