December 2, 2023

Among community-dwelling adults aged ≥50 years in Ontario, VE against Omicron-associated severe outcomes increased with booster doses of monovalent mRNA COVID-19 vaccines, but protection waned over time after each dose. Third doses continued to provide strong protection (85–87%) against severe outcomes among subjects aged 50–69 years even 8 months after vaccination, but lower protection (76–79%) among those aged ≥70 years. Fourth doses restored waning of protection from third doses and continued to provide strong protection (86–89%) 4 months after vaccination for all age groups. However, VE in the BA.4/BA.5-predominant period was lower than during the BA.1/BA.2-predominant period across the same time intervals after vaccination, especially with increasing time since vaccination.

Comparisons with other jurisdictions are challenging due to heterogeneity in study designs, population characteristics, outcomes and exposures, vaccines, and observation periods. Our fourth dose VE estimates were slightly higher than those observed in the United States, where fourth dose VE against hospitalizations was 80% (95%CI, 71–85%) after ≥7 days among adults aged ≥50 years10. Studies from Israel found that waning of protection against severe outcomes was significantly slower than against infection and that marginal effectiveness of booster doses against infection waned faster after fourth doses compared to third doses11,12,13. They were unable to determine if trends were similar for severe outcomes due to the short follow-up period. In our study, the waning of protection against severe outcomes observed ≥120 days after a fourth dose was comparable to that seen 120–179 days after a third dose. Although differences in timing of vaccination within those time periods may influence VE estimates, the median time since vaccination was 141–145 days (depending on the age group) for the 120–179 days post third dose group and 140–147 days for the ≥120 days post fourth dose group, suggesting that waning of protection after a fourth dose may follow a similar trajectory as after a third dose.

Available evidence on VE of monovalent COVID-19 vaccines against severe outcomes among adults aged ≥18 years caused by the BA.4/BA.5 Omicron sublineages varies. In the UK, compared to a second dose, marginal effectiveness of a third or fourth dose against BA.4/BA.5- versus BA.2-related hospitalizations was similar using the same time intervals since vaccination14. Similarly, VE of a third dose against hospitalizations was comparable between BA.1/BA.2-predominant and BA.4/BA.5-predominant periods in South Africa15. Conversely, in Portugal, 3-dose protection against severe outcomes was lower among BA.5 versus BA.2 cases16. A study among Kaiser Permanente members found that VE of third and fourth doses against BA.4/BA.5-related hospitalizations was lower compared to BA.1/BA.2-related hospitalizations, whereas another study among individuals admitted to IVY Network hospitals saw this difference for a third dose but not for 2 or 4 doses17,18. The IVY Network study reported 3-dose VE of 79% (95% CI, 74–84%) and 60% (95% CI, 12–81%), respectively, during the BA.1/BA.2-predominant versus BA.4/BA.5-predominant periods 7–120 days after vaccination18.

Potential explanations for lower VE during the period of BA.4/BA.5-predominance compared to BA.1/BA.2-predominance include longer intervals between booster dose receipt and outcomes, increased incidence of undocumented infections, and increased BA.4/BA.5 immune evasion17. In our study, differences in the median numbers of days since booster receipt between the BA.1/BA.2-predominant versus BA.4/BA.5-predominant periods were always <30 days, so longer post-booster follow-up during the BA.4/BA.5-predominant period was unlikely to be a major contributor to the large observed differences in VE. VE may be underestimated in the setting of undocumented infections if unvaccinated individuals are more likely to be infected than vaccinated individuals because the former will have infection-induced immunity, and the extent of VE underestimation may increase as prior infections become more prevalent in the population. During the BA.1/BA.2-predominant period, infection-acquired seroprevalence in Ontario in the overall population increased from 6% to 50% and subsequently increased from 50% to 63% during the BA.4/BA.5-predominant period9. Seroprevalence was lower among adults aged ≥60 years9. However, we noted that VE declined considerably faster as time since vaccination increased during the relatively brief BA.4/BA.5-predominant period (only 3 months) compared to the BA.1/BA.2-predominant period, suggesting that bias from undocumented prior infections is unlikely to account entirely for the differences. Therefore, among these potential explanations, increased immune evasion by BA.4/BA.5 sublineages is likely the largest contributor to these differences in VE.

Based on the evidence to date, the level of protection offered by bivalent vaccines remains unclear. Findings from a phase 2-3 trial suggest that Moderna’s bivalent vaccine elicits higher titres of neutralizing antibodies against Omicron sublineages BA.1 and BA.4/BA.5 compared to Moderna’s ancestral monovalent vaccine19. In contrast, two observational immunogenicity studies found the Pfizer and Moderna bivalent vaccines elicited similar levels of neutralizing antibodies against BA.4/BA.5 as the ancestral monovalent vaccines20,21.

This study had some limitations. First, data on rapid antigen tests were not available, and this was the main source of testing after December 31, 2021, when eligibility for RT-PCR testing was restricted in Ontario to individuals considered at high risk of acquiring SARS-CoV-222. Thus, while we adjusted for prior SARS-CoV-2 infections documented by RT-PCR, we could not account for prior infections confirmed only by rapid antigen tests. This could bias VE estimates downward or upward depending on whether unvaccinated or vaccinated individuals are more likely to have prior undocumented infections. Second, because whole genome sequencing was not performed on all cases, we were unable to estimate VE against BA.1, BA.2, BA.4, and BA.5 separately but instead combined BA.1 and BA.2 during one period and BA.4 and BA.5 during another period based on when each grouping circulated. Last, there remains the potential for residual confounding since we were limited to the covariates available in the databases used. Unmeasured differences between unvaccinated and vaccinated individuals may introduce bias, but the consistency between the VE and marginal effectiveness estimates is reassuring. A significant strength of our study is the length of the follow-up period, allowing us to estimate VE ≥ 4 months after fourth doses. Also, unlike most other studies, we stratified our analyses by age group, which provides more refined VE estimates for decision-making.

Our findings suggest that while booster doses of monovalent mRNA COVID-19 vaccines initially restore strong protection against Omicron-associated hospitalizations and death among community-dwelling older adults and then subsequently wane over time, much uncertainty remains. Although protection remained strong 4 months after a fourth dose for all age groups, whether waning increases past this period remains unknown, and combined with the evidence of reduced VE against BA.4/BA.5 sublineages and the possibility that vaccines could be even less effective against newly emerging sublineages such as BQ.1.1 and XBB, subsequent boosters and other measures (e.g., face masks, improved ventilation, filtration of indoor air) may be needed to mitigate the impact of Omicron and future SARS-CoV-2 variants. It will be important to continue monitoring VE given the scarcity of VE data against BA.4/BA.5, newly emerging sublineages, and the introduction of bivalent vaccines.


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