As much of the world returns to normal, people with cancer continue to be at greater risk for COVID-19. But this risk is not evenly distributed: People with blood cancers and those receiving immune-suppressing treatments are most prone to severe illness and inadequate vaccine protection.

In September, the National Comprehensive Cancer Network (NCCN) released updated COVID vaccine recommendations.

The guidelines advise that people with cancer should receive a new bivalent booster, note that the vaccines are safe for patients receiving immunotherapy and recommend revaccination after receiving a stem cell transplant or CAR-T therapy. The revised guidelines also add recommendations for children with cancer.

The Pfizer-BioNTech and Moderna bivalent boosters, authorized by the Food and Drug Administration (FDA) in August, protect against both the original SARS-CoV-2 strain and BA.4 and BA.5 omicron variants. The Centers for Disease Control and Prevention recommends a bivalent booster for all adults and for children ages 5 and up. It can be administered two months after the last shot or at least three months after a bout of COVID. The FDA also recently authorized the new Novavax vaccine, but NCCN does not recommend it due to limited data on its effectiveness for cancer patients.

Because some people with cancer don’t respond as well to vaccines, NCCN recommends the monoclonal antibody combination Evusheld (tixagevimab plus cilgavimab) as pre-exposure prophylaxis for immunocompromised patients. However, the FDA recently warned that Evusheld may not be as effective against certain SARS-CoV-2 variants. For maximum protection, experts recommend that people with cancer continue to wear a mask, maintain social distancing and avoid crowds.

“We’re at a new stage of COVID,” says Steve Pergam, MD, of the Fred Hutchinson Cancer Center in Seattle. “We’ve moved from control and prevention into a phase that’s about openness and getting back to reality. That’s a hard shift for the immunocompromised.”