France routinely recommends third dose of COVID-19 vaccine for some people with reduced immune function
Numerous studies have now reported that two doses of an mRNA COVID-19 vaccine are insufficient to generate immune responses in some people with reduced immune function.
Based on these results, the French Vaccine Strategy Guidance Council routinely recommends a third dose in people who are severely immunocompromised. [1, 2, 3]
This includes a broad range of situations including:
- Solid organ transplants.
- Recent bone marrow transplants.
- People on dialysis.
- Autoimmune diseases.
- People under strong immunosuppressive treatment (anti-CD20 or anti-metabolites).
The third dose is recommended four weeks after the second dose, or as soon as possible for people who have already exceeded this time.
The guidelines stress the importance of further data in these populations and for medical records to record the third dose.
They recommend that all severely immunocompromised people receive a quantitative anti-S type serology 30 days after administration of the second dose and the third dose. People also need to be rapidly informed that two doses of any vaccine is only likely to provide very limited protection.
Further updates will be posted including on whether a third dose will also be recommended for other groups, including:
- Chronic kidney disease without dialysis.
- Auto-immune diseases using other immunosuppressive treatments.
- People being treated for cancer.
The 3 May edition of HTB included two studies of suboptimal vaccines responses, one in people older than 80. We used these examples to raise the importance of data on vaccine responses in HIV positive people at low CD4 counts, including under 50 cells/mm3. 
Recent cases have also been reported where anti-CD20 therapies including rituximab have been associated with a lack of humoral responses following recovery from COVID-19 leaving people vulnerable to second infections. 
Although data is now needed on whether a third dose generates significantly higher response rates, the high risk of COVID-19 supports this approach.
Some of the studies referenced in the French guidelines include cases of severe COVID-19 experienced by people more than two weeks after receiving a second vaccine dose. These include ICU admission and mortality.
While France accumulates the first early data, the UK are not currently planning to decide on use of a third dose until the Autumn (not confirmed, but likely).
BHIVA has approached the Department of Health and Social Care (DHSC) to ask that HIV positive people with CD4 <50 cells/mm3 be included if such a recommendation is made.
BHIVA has also repeated advice “that people with a low CD4 count and/or other health conditions, should continue to take extra precautions, including working from home where possible, although everyone in this group should have been vaccinated by now”. 
- Conseil d’Orientation de la Stratégie Vaccinale Avis du 6 avril 2021: Elargissement des priorités d’accès à la vaccination anti-Covid-19. (6 April 2021).
- Precisions sur la vaccination COVID-19: modalites d’administration des rappels et vaccination des personnes immunodeprimes et de leurs proches. (6 May 2021). (6 May 2021)
- Google translate.
- Low responses to mRNA COVID-19 vaccines in those older than 80 vs <60 years and in recipients of solid organ transplants. HTB (3 May 2021).
- Friedman MA et al. Second COVID-19 infection in a patient with granulomatosis with polyangiitis on rituximab. Annals of the Rheumatic Diseases. DOI: 10.1136/annrheumdis-2021-220088. (4 March 2021).
- BHIVA statement. COVID risk and vaccine updates. (12 May 2021).
This report was frist posted on 11 May 2021.