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

AFL 22-09.1
June 14, 2023

All Facilities

Coronavirus Disease 2019 (COVID-19) Vaccine and Booster Recommendations for Clinically Eligible Individuals
(This AFL supersedes AFL 22.09)

​​​​​This AFL has been superseded - please see AFL 23-34​. ​​​​​​​

​All Facilities Letter (AFL) Summary​​

  • The California Department of Public Health (CDPH) recommends facilities offer COVID-19 vaccinations and booster doses to clinically eligible individuals. 
  • This revision includes updated information related to bivalent booster doses.


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, residents, staff, and the community from COVID-19.

This AFL reminds facilities of the importance of offering and encouraging COVID-19 vaccinations to clinically eligible individuals, especially those at highest risk of morbidity and mortality, at all interactions across the healthcare continuum.  

Overview of COVID-19 Vaccina​​tion

The Centers for Disease Control and Prevention (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 Wh​o 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 Imm​unocompromised

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

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 age 85 years and older are at highest risk, accounting for 40 percent of adults dying of COVID-19.

Other Resource​s

For assistance in obtaining COVID-19 vaccinations, please direct patients to consult their primary care provider or to the MyTurn or CDC Vaccines websites.

Facilities 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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