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The Food and Drug Administration strictly limited use of the Johnson & Johnson COVID vaccine on Thursday.

The Johnson & Johnson vaccine was tied to 60 cases of a rare blood clotting disease called thrombosis with thrombocytopenia syndrome. Nine people have died from TTS caused by the vaccine, according to the FDA.

Now, the Johnson & Johnson vaccine is only recommended for people who cannot access another vaccine or people who have conditions that make the mRNA vaccines developed by Pfizer and Moderna more dangerous.

The FDA also said that anyone who specifically demands the Johnson & Johnson vaccine and refuses the other shots can receive the J&J jab.

“Our action reflects our updated analysis of the risk of TTS following administration of this vaccine and limits the use of the vaccine to certain individuals,” said Dr. Peter Marks, director of the FDA’s Center for Biologics Evaluation and Research.

The one-shot Johnson & Johnson vaccine is marginally less effective at preventing COVID infection and severe illness than the Pfizer and Moderna vaccines. Nonetheless, U.S. public health officials stressed in early 2021 that “the best vaccine is the one that you can get the soonest.”

In April 2021, use of the Johnson & Johnson vaccine was paused for about a week before injections resumed. In December, a Centers for Disease Control panel recommended the Pfizer and Moderna vaccines as superior to the Johnson & Johnson shot.

Only about 18 million doses of the Johnson & Johnson vaccine have been administered, compared to 340 million doses of the Pfizer vaccine and 217 million doses of the Moderna vaccine, according to CDC data. People who got a Johnson & Johnson shot months ago are not at risk of developing TTS. The clots develop between one and three weeks after vaccination.

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