Who Will Get the Vaccine First?

One COVID-19 vaccine is already under review for possible emergency authorization in December; its competitors are close behind. Once we have a vaccine—or maybe several—it will be a while until there are enough doses for everybody. The CDC is working on a plan to prioritize certain groups of people to get it first.

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

With COVID-19 vaccine development proceeding at a record-setting pace, ACIP has been discussing the vaccines over the past several months, aiming to be ready to make recommendations as soon as possible once a vaccine is approved or authorized. One of the key decisions the committee will have to make: who should get the vaccine first?

Yesterday the committee published their ethical framework for making these decisions, and at a meeting the same day they publicly mulled over the possible priority groups. (ACIP meeting webcasts are available to the public, and you can see agendas and slides from the meetings here.)

The priority groups have not been finalized, and states may have some leeway to make their own decisions on top of these, but here is what the committee is considering:

Healthcare workers will probably be top priority

There seems to be agreement that “healthcare personnel” should be first in line to receive the vaccine. These people include not just doctors and nurses, but also people like pharmacists, emergency responders, and staff at hospitals and nursing homes. ACIP estimates there are about 21 million Americans in this group.

By helping these workers first, we’re enabling them to stay healthy enough to treat others. This not only keeps COVID treatment available, but also enables those workers and their employers to provide care for people with other health issues. Healthcare personnel are also close contacts of the residents or patients they work with, so protecting them protects those other people.

There are also practical reasons why it makes sense to vaccinate these workers first. Many hospitals and healthcare facilities already have the equipment (like ultra-cold freezers) to store and administer vaccines, and healthcare workers are already used to getting vaccines; more healthcare workers get flu vaccines than people in the general population.

Healthcare workers are also racially and ethnically diverse, which fits one of the main ethical considerations: to avoid exacerbating existing injustice, and to make things as fair and just as possible.

Nursing home residents are also high priority

In the timeline set out in the most recent ACIP meeting, residents of “long-term care facilities” including nursing homes and inpatient rehab centers will be in the first group, along with healthcare personnel. There are about three million people in this group.

These residents are often elderly and with high-risk medical conditions, and they bear the brunt of outbreaks. Staff and residents of these facilities account for 6% of COVID-19 cases and a whopping 39% of all COVID-19 deaths, a presentation said.

Essential workers will likely be next

As the first group of healthcare personnel and long-term care facility residents winds down, “phase 1b” of vaccination will begin. According to the committee’s current thinking, these will be essential workers from industries other than healthcare. There are about 87 million people in this group.

The definition of “essential workers” is up to a government agency called CISA, which has a report on them here. Examples include people who work in the food, agriculture, and transportation industries, people who work in manufacturing, people who operate water and wastewater treatment plants, police, firefighters and teachers, to name a few.

Protecting these people protects the rest of us, in much the same way as healthcare workers, while still allowing essential functions of society to operate as much as possible. About a quarter of these workers are low income, and this group is more diverse than the country as a whole. Ethically, this helps to right some of the injustice that they face in being more at risk for the coronavirus in the first place.

Older adults and those with high-risk medical conditions are next

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:

Children aren’t in any of these groups, in part because they weren’t included in vaccine trials. (Some companies enrolled teenagers in their trials; none are testing the vaccine on young children.) Younger and middle-aged adults who work from home and don’t have serious medical conditions (this includes myself) probably won’t be able to get the vaccine in the first few months it’s available.

To be clear, these priority groups are still tentative, and they are only for the initial rollout while vaccine availability is limited. Once there is enough vaccine to give to everyone who wants it, the priority groups will not be used anymore. Vaccine distribution will be up to 64 jurisdictions, representing states, territories, and tribal authorities who will have some leeway in how they organize the vaccine rollout.

If the Pfizer vaccine is approved in December, the company plans to ship out enough vaccine immediately to immunize three million people. More doses will follow, with Pfizer estimating they can provide 50 million doses worldwide by the end of 2020, and growing from there. Moderna’s vaccine may not be far behind, and the AstraZeneca/Oxford vaccine could be available not long after that. Experts seem to expect that people in priority groups will be able to receive their vaccines in the first few months of 2021, with doses becoming available to the rest of us by spring or summer.

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

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