Who Gets the Vaccine First?

One COVID-19 vaccine is already pending for possible emergency relief in December; its competitors are just around the corner. Once we have a vaccine – or maybe a few – it will take some time before we get enough doses for everyone. The CDC is working on a plan to prioritize certain groups of people who get it first.

The Advisory Committee on Immunization Practices , or ACIP, is part of the CDC that makes recommendations on vaccines. During normal times, their work is invisible to most of us, but they are the ones who say that we should get the flu shot every year, that babies should be vaccinated against measles at the age of one, and so on. The FDA decides whether a vaccine should be approved at all, and then the ACIP decides who should get it. (Under the Affordable Care Act, your insurance must cover the cost of the vaccine if you are in a group for which ACIP recommends the vaccine.)

As development of a COVID-19 vaccine progresses at a record pace, ACIP has been discussing vaccines over the past few months, aiming to be ready to make recommendations as soon as possible after a vaccine is approved or authorized . One of the key decisions to be made by the committee is who should get the vaccine first?

The committee published its ethical framework for making these decisions yesterday, and at the same day meeting, they publicly discussed possible priority groups. (Webcasts of ACIP meetings are available to everyone, and you can see meeting agendas and slides here .)

Priority groups have yet to be identified, and states may have some leeway to make their own decisions beyond them, but here’s what the committee is considering:

Healthcare professionals are likely to be a priority

There appears to be an agreement that “medical personnel” must be first in line to receive the vaccine. These people include not only doctors and nurses, but also people such as pharmacists, emergency services, and hospital and nursing home staff. The ACIP estimates that there are about 21 million Americans in this group.

By helping these workers first, we enable them to stay healthy enough to heal others. This not only ensures the availability of COVID treatment, but also allows these workers and their employers to provide care to people with other health problems. Medical staff are also in close contact with residents or patients with whom they work, so their protection protects other people.

There are also practical reasons why it makes sense to vaccinate these workers first. Many hospitals and health care facilities already have equipment (such as ultracold freezers) to store and administer vaccines, and healthcare workers are accustomed to receiving vaccines; more health care workers receive influenza vaccines than people in general.

Health care providers are also racially and ethnically diverse, in line with one of the basic ethical considerations: avoid exacerbating existing injustices and making things as fair as possible.

Nursing home residents also have a high priority.

According to the schedule set at the last ACIP meeting, residents of “long-term care facilities”, including nursing homes and inpatient rehabilitation centers, will be in the first group along with medical personnel. There are about three million people in this group.

These residents are often senior citizens with high-risk illnesses and bear the brunt of outbreaks. The presentation says staff and residents of these institutions account for 6% of COVID-19 cases and a whopping 39% of all COVID-19 deaths.

Key workers are likely to be as follows

As the first group of nursing staff and long-term care patients closes, “phase 1b” vaccinations will begin. The committee’s current view is that these will be important workers from other industries besides healthcare. There are about 87 million people in this group.

The definition of “key workers” remains with the government agency CISA, which has a report on them here . Examples include people who work in the food, agricultural and transportation industries, people who work in manufacturing, people who operate waste water treatment plants and wastewater treatment plants, police, firefighters and teachers, and many others.

Protecting these people protects all of us, in much the same way as medical professionals, while allowing the most important functions of society to be performed to the greatest extent possible. About a quarter of these workers are low-income workers, and this group is more diverse than the country as a whole. From an ethical point of view, this helps to correct the injustices they face primarily due to the increased risk of contracting the coronavirus.

Elderly people and people with high-risk illnesses are next.

We come to the last of three overlapping stages: once a large number of key workers have the opportunity to be vaccinated, adults at increased risk of contracting coronavirus are likely to fall into the third priority group (1c).

There are over 100 million adults with high-risk illnesses, and some of them will be vaccinated earlier. There are also about 53 million adults aged 65 and over, or 50 million if you subtract those in care facilities. (Again, there will be some overlap with healthcare professionals and key workers, so these numbers may be lower by the time this group can be vaccinated.)

These populations are important because they have a high risk of complications and death. They fall on the priority list lower than the groups above, in part because these groups will be more difficult to vaccinate everyone. (They also represent a less fair cross-section of Americans in the sense that the higher you are in a privileged position, the more likely you are to have access to health care to diagnose a high-risk condition, and the more likely you are to stay. live to old age.)

Overall plan

With these considerations in mind, the preliminary plan, which, again, may change, looks something like this:

• Group 1a: medical personnel and residents of long-term care institutions.
• Group 1b (same as 1a): other important workers.
• Group 1c (same as 1b): elderly people and adults with high-risk diseases.

Children are not in any of these groups, in part because they did not participate in vaccine trials. (Some companies have recruited teenagers in their trials; none are testing the vaccine on young children.) Young to middle-aged adults who work from home and do not have serious illnesses (myself included) probably won’t get the vaccine in the first few months is available.

To be clear, these priority groups are still provisional and are for initial deployment only, while vaccine availability is limited. Once there is enough vaccine to give everyone, priority groups will no longer be used. Distribution of the vaccine will take place across 64 jurisdictions representing states, territories and tribal authorities, which will have some leeway in how they organize vaccine introduction.

If Pfizer’s vaccine is approved in December, the company plans to immediately ship enough vaccine to immunize three million people. More doses will follow, and Pfizer estimates that by the end of 2020 they will be able to deliver 50 million doses worldwide, and that number will continue to grow from now on. The Moderna vaccine may not be far behind, and the AstraZeneca / Oxford vaccine may be available shortly thereafter. Experts seem to expect priority populations to be able to receive their vaccines in the first few months of 2021, with doses available to all of us by spring or summer.

It all depends on trial data and post-authorization studies that the vaccine works and is safe. But it’s good to know that there is a plan and that it is being formulated with public health and ethics in mind.