Vaccine group prioritizes frontline essential workers, older adults for next round of COVID-19 vaccination

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Frontline essential workers and people ages 75 and older should be next in line to receive a COVID-19 vaccine, a national expert group said Sunday.

Those priority groups would be followed by people who are ages 65 to 74, people ages 16-64 with high-risk medical conditions and other essential workers. The Centers for Disease Control and Prevention’s (CDC’s) Advisory Committee on Immunization Practices (ACIP) approved the recommendation with a 13-1 vote. If the CDC director accepts ACIP’s recommendation, the CDC will provide more guidance on how to implement each phase.

“I voted for this recommendation because in my opinion it followed the evidence about the risks from coronavirus and ethical principles that we have developed on ACIP to maximize benefits and minimize harms, promote justice and mitigate health inequities,” said ACIP member Peter G. Szilagyi, M.D., M.P.H., FAAP. “… This was a difficult decision for me, really difficult because I truly wish everyone could get the vaccine today.”

Over the past 10 days, the Food and Drug Administration (FDA) has granted emergency use authorization to two vaccines — one from Pfizer and BioNTech for people ages 16 and older and another from Moderna for people ages 18 and older. The two are 95% and 94% effective, respectively, with no serious safety concerns in clinical trials.

Just over 556,000 doses of the Pfizer vaccine had been administered as of Sunday afternoon, according to the CDC. Administration of the Moderna vaccine will begin Monday after receiving the green light from the FDA and CDC over the past several days. The first doses have been going to health care workers and residents of long-term care facilities in what has been designated phase 1a.

In crafting the next phases, CDC experts said they tried to balance prevention of sickness and death while preserving the ability of society to function. Phase 1b consists of about 49 million people ages 75 and older and frontline essential workers. People in the older group account for 25% of COVID-19 hospitalizations while making up only 8% of the population and have high rates of death from COVID-19, according to the CDC.

The frontline essential workers include firefighters, police officers and workers in education, food and agriculture, manufacturing, corrections, the U.S. Postal Service, public transit and grocery stores. This group is at high risk of contracting COVID-19 and includes many workers from racial and ethnic minority groups who have been disproportionately impacted by COVID-19.

Group 1c consists of about 129 million people ages 65-74, ages 16-64 with high-risk medical conditions and other essential workers. The list of medical conditions for adults includes obesity, severe obesity, type 2 diabetes, chronic obstructive pulmonary disease, heart condition, chronic kidney disease, cancer, immunocompromised state from solid organ transplant, sickle cell disease, pregnancy and smoker (current or past). However, the list has been evolving and is not considered exhaustive. The CDC recommends people talk to their health care providers about their personal risk.

The additional essential workers in phase 1c include people in transportation, food service, shelter/housing (construction), finance, information technology, energy, media, legal, public safety (engineers) and water/wastewater industries.

“For every group we add, it means we subtract a group,” said ACIP member Helen “Keipp” Talbot, M.D., M.P.H. “For every group we subtract, it means they don’t get the vaccine and it’s incredibly humbling and heartbreaking, and I look forward to everyone having this vaccine.”

ACIP member Henry Bernstein, D.O., M.C.H.M., FAAP, was the lone no vote, saying people ages 65-74 should be included in group 1b instead of 1c because they have a high risk of hospitalization and death.

For pediatricians, ACIP’s prioritization means they and their staffs are currently eligible for a vaccine. Their 16- and 17-year-old patients also would be eligible if they fall into one of the employment groups or have certain underlying conditions. The AAP has continued to push for children to be included in clinical trials. In the meantime, David Kimberlin, M.D., FAAP, AAP Red Book editor and a liaison to ACIP, said he was pleased to see teachers and child care staff included in the 1b priority group, which will benefit children.

While ACIP provided a framework for distribution, the decisions ultimately will be up to state and local health officials. Officials said they expect to have enough doses available to vaccinate 20 million people this month, 30 million in January and 50 million in February. There may not be enough doses for everyone who wants to be vaccinated until summer.

Several members said there should be additional prioritization within phase 1c due to its size. Some called for more information about when to vaccinate people in jails, in homeless shelters and people who fall into an essential worker category but can work from home. Members also asked for more clarity about which additional medical conditions make someone high risk.

Some people in the priority groups will be challenging to vaccinate, including those in rural areas, those who are uncomfortable with the medical community or the vaccine, and those who can’t take time off work for vaccination.

Many of the ACIP members and liaisons stressed the need for the federal government to provide funding for state and local health departments to run vaccine clinics and provide public outreach.

“The fact that state and local health departments have not been funded for vaccination programs especially in the context of the billions of dollars that funded the extremely successful program to develop vaccines is really appalling,” said Beth P. Bell, M.D., M.P.H., who led the ACIP work group on COVID-19 vaccines. “… I hope that the government will address this discrepancy without which I think it’s going to be very difficult for us to be successful.”