Photo Credit: Yossi Zeliger/Flash90
Healthcare worker about to administer a 4th dose of the COVID-19 vaccine at the Sheba Medical Center.

The Director-General of the Health Ministry, Prof. Nachman Ash, on Thursday approved a fourth vaccine for immunosuppressed patients who have been vaccinated three times. According to Reshet Bet radio, Israel’s HMOs have already begun to vaccinate the immunosuppressants on Friday morning.

A ministry’s press release explained that the State of Israel is in the fifth wave of morbidity of the Corona, and at the same time, we are witnessing a decrease in the level of protection against the virus among those vaccinated against Corona (including with three doses) as time passes from the date of vaccination.


The patients at the highest risk are immunocompromised patients. Studies show that a significant percentage of immunocompromised people do not develop a serological response—meaning the presence of antibodies—after receiving three doses of the corona vaccine. The studies also show that some develop a serological response after receiving a fourth dose of the vaccine.

In light of the increased risk of immunosuppressants in the current morbidity, and in light of the safety and benefits data of the third vaccine, it was decided to recommend the administration of a fourth vaccine dose to patients with immunosuppression aged 18 years and older.

The fourth dose of vaccine will be given on the condition that at least 4 months have passed since the date of receiving the third dose of vaccine.

The following patients are included in the recommendation for a fourth vaccine dose due to immunosuppression:

● Heart, lung, kidney, and liver transplant recipients
● Patients with rheumatological or autoimmune diseases treated with one or more of the following drugs:
– Anti-CD20 treatment such as rituximab or obinutuzumab
– Mycophenolate mofetil (MMF)
– Abatacept
– Prednisone at a dose of 20 mg per day regularly
● Patients with multiple sclerosis treated with fingolimod or ocrelizumab
● Patients with primary immunodeficiency.
● Patients with hematologic malignancies following the decision of a professional doctor who specializes in treating the disease:
– Patients with chronic lymphocytic leukemia
– Patients with multiple myeloma receiving treatment for their disease
– Patients with non-Hodgkin’s indolent lymphoma
– Patients with aggressive non-Hodgkin’s lymphoma up to 3 years after the end of treatment
– Patients who underwent autologous stem cell transplantation and received the first two vaccines before transplantation
– Patients who have had a donor stem cell transplant from a donor – as recommended by the transplant doctor
– Patients receiving CAR-T treatment

In any case, a fourth vaccine will not be given within 6 months of anti-CD20 therapy such as rituximab or obinutuzumab.

The professional physicians who treat the disease must assist in locating patients who meet the recommended indications for administering the fourth dose of vaccine and referring them to their HMO to receive the vaccine.

If there is an immunosuppressed patient who does not meet one of the criteria and in the opinion of the professional doctor treating the disease that causes immunosuppression it is necessary to give them a fourth vaccine dose already at this stage, it will be possible to vaccinate according to the said recommendation.

It is preferable to give the fourth dose of an mRNA vaccine, preferably with the same vaccine in which the patient started the vaccination series. For a person who is prevented from receiving an mRNA vaccine, an Astra-Zenka vaccine may be given as a fourth dose. The fourth dose will be given at the same dosage as the third.

The immunosuppressants listed above will be able to receive a fourth dose even if they have recovered from COVID 19 at some point.


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