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A COVID-19 vaccine is currently under review for emergency authorization, with others in the pipeline. However, once we have a vaccine—or perhaps several—it will take time before there are enough doses for everyone. The CDC is working on a strategy to determine who will get it first.
The Advisory Committee on Immunization Practices (ACIP) is a division of the CDC responsible for vaccine recommendations. While their role is often unnoticed, they decide on vaccines like the annual flu shot, and childhood immunizations. After the FDA approves a vaccine, ACIP determines who should receive it. Under the Affordable Care Act, vaccines recommended by ACIP must be covered by insurance.
As COVID-19 vaccine development progresses at an unprecedented speed, ACIP has been reviewing vaccines for several months to prepare for the moment they are authorized. A major decision they face is who should be the first to receive the vaccine.
The committee released their ethical framework for making vaccine distribution decisions yesterday, and during the same day's meeting, they discussed potential priority groups. (Public webcasts of ACIP meetings are available, and you can access agendas and slides from these sessions here.)
The priority groups have not yet been finalized, and states may have some flexibility to make additional decisions, but here's what the committee is considering so far:
Healthcare workers are likely to be at the top of the priority list.
There seems to be a consensus that 'healthcare personnel' should be the first to receive the vaccine. This group includes not only doctors and nurses but also pharmacists, emergency responders, and staff at hospitals and nursing homes. ACIP estimates this group includes around 21 million Americans.
By prioritizing healthcare workers, we are ensuring they remain healthy enough to care for others. This not only maintains COVID treatment availability but also allows these workers and their employers to continue providing care to people with other health issues. Furthermore, as healthcare workers are in close contact with patients, protecting them also protects the people they serve.
There are practical reasons for prioritizing these workers as well. Many hospitals and healthcare facilities are already equipped with necessary tools (such as ultra-cold freezers) to store and administer vaccines, and healthcare workers are accustomed to receiving vaccines; more healthcare workers get flu shots compared to the general population.
Healthcare workers are also a diverse group, racially and ethnically, which aligns with one of the main ethical principles: preventing further injustice and striving to make the distribution as fair and equitable as possible.
Residents of nursing homes are another group given high priority.
According to the timeline outlined in the latest ACIP meeting, residents of 'long-term care facilities,' including nursing homes and inpatient rehabilitation centers, will be prioritized along with healthcare workers. Approximately three million individuals fall into this category.
These residents are typically elderly and often have high-risk medical conditions, making them especially vulnerable to outbreaks. Both staff and residents of these facilities account for 6% of COVID-19 cases and a staggering 39% of all COVID-19-related deaths, as noted in a presentation.
Essential workers are likely to be the next group to receive the vaccine.
As the initial phase of healthcare workers and long-term care facility residents finishes, 'phase 1b' of vaccination will begin. According to the committee's current plans, this phase will target essential workers in industries outside of healthcare. This group includes approximately 87 million people.
The definition of 'essential workers' is determined by a government agency called CISA, which has a report available here. This category includes workers in industries such as food, agriculture, transportation, manufacturing, water and wastewater treatment, as well as police officers, firefighters, and teachers, among others.
Vaccinating essential workers helps protect everyone, just as it does for healthcare workers, while ensuring that vital societal functions continue. Approximately a quarter of these workers earn low incomes, and this group is more diverse than the overall population. Ethically, this helps address some of the injustice they face due to their higher risk of exposure to the virus.
Older adults and individuals with high-risk medical conditions will be the next group to be vaccinated.
We come to the last of the three overlapping phases: After a large number of essential workers have had a chance to be vaccinated, adults who are at extra risk from the coronavirus will likely be in the third priority group (1c).
There are over 100 million adults with high-risk medical conditions, and some will have been vaccinated as part of the earlier phases. There are also about 53 million adults who are age 65 and older, or 50 million once you subtract those in care facilities. (Again, there will be some overlap with healthcare workers and essential workers, so these numbers may be smaller by the time this group is able to be vaccinated.)
These populations are important because they have a high risk of complications and death. They fall lower on the priority list than the groups above, in part because it will be harder to get the vaccine to everybody in these groups. (They are also a less equitable cross section of Americans, in the sense that the more privileged you are, the more likely you are to have access to healthcare to be diagnosed with a high-risk condition, and the more likely you are to live to old age.)
The overall plan
With these considerations, the tentative plan—which, again, could change—looks something like this:
Group 1a: healthcare workers and residents of long-term care facilities.
Group 1b (which overlaps with 1a): other essential workers.
Group 1c (which overlaps with 1b): older adults and adults with high-risk medical conditions.
Children aren't included in any of these priority groups, partly because they weren't part of vaccine trials. (Some companies included teenagers in their trials, but none tested the vaccine on younger children.) Adults who work from home and don't have serious health conditions (like myself) will likely have to wait until later months to receive the vaccine.
It's important to note that these priority groups are still provisional, and they only apply during the initial distribution when vaccines are limited. Once there’s enough vaccine to meet demand, these priority groups won’t be used anymore. Distribution will be managed by 64 jurisdictions, which include states, territories, and tribal authorities, each of which will have some flexibility in how they handle the rollout.
If the Pfizer vaccine is authorized in December, the company plans to immediately ship enough doses to vaccinate three million people. Additional doses will follow, with Pfizer expecting to provide 50 million doses globally by the end of 2020, and more after that. Moderna’s vaccine may follow soon after, and the AstraZeneca/Oxford vaccine might not be far behind. Experts predict that people in priority groups will begin receiving vaccines in early 2021, with general availability by spring or summer.
This all hinges on trial results and post-authorization studies confirming the vaccine's safety and efficacy. But it's reassuring to know that there is a clear plan, one that prioritizes public health and ethical considerations.
