Who should be first?
Experts consider COVID-19 vaccine priority for health-care and essential workers, and people of color
With some coronavirus vaccine trials in their much-anticipated final stage, U.S. officials and experts are wrestling with one of the most difficult issues facing the country: Who should be first to get limited doses of a vaccine?
Discussions have begun to identify priority groups for initial vaccination against COVID-19, the disease caused by the virus. Those discussions, involving federal health officials and outside experts, are based on planning developed during the 2009 H1N1 influenza pandemic. Highest priority would go to health-care and essential workers and high-risk populations. This proposed group would also include older adults, residents of long-term-care facilities and people with underlying medical conditions.
A federal advisory panel that provides vaccine recommendations to the Centers for Disease Control and Prevention presented an overview of the priority groups last month and is scheduled to meet again.
As officials and experts race to stop the pandemic, they are grappling with the fraught nature of establishing vaccination priorities. Clinical trials of at least two experimental vaccines have shown encouraging results and moved into final-stage testing for safety and effectiveness. If a vaccine is shown to be effective, U.S. officials have said the first doses could be available by the end of the year.
The decision-making will take place over the next few months and is certain to be controversial, experts said. Officials and experts must address a host of issues, including how much consideration should be given to race and ethnicity because of the disproportionate impact of COVID-19 on communities of color. Aside from doctors and nurses, will cafeteria workers and cleaning staff at hospitals be considered essential personnel? What about teachers?
“This is going to be controversial and not everybody’s going to like the answer,” said Francis Collins, director of the National Institutes of Health, referring to the process of establishing priorities. He spoke at the kickoff meeting of a committee of experts helping with planning.
That committee of experts is developing a framework to help the federal advisory panel and the CDC set final vaccination priorities. The experts are from an independent advisory group, the National Academies of Sciences, Engineering and Medicine, and from the National Academy of Medicine. The panel was formed at the request of the directors of the NIH and the CDC.
The overview of proposed priority groups laid out by the federal advisory panel includes subsets within those that should get the highest consideration. At the top of the list: an estimated 12 million critical healthcare and other workers. The first doses would go to a subset described as “highest risk medical, national security, and other essential workers” needed to protect health-care infrastructure and critical societal functions, according to presentations and discussions at the June meeting of the Advisory Committee on Immunization Practices.
But what’s at stake goes beyond allocation of the first shots. The process of identifying priority groups is a chance for health officials and scientists to adjust sometimes-unrealistic expectations about when a vaccine is likely to be available.
In addition to essential workers and those most affected by health disparities, Collins said a priority list should include the military and locations where the virus is most active. He said the committee should consider giving priority to volunteers in vaccine clinical trials who received a placebo.
During Wednesday’s meeting of the CDC’s Advisory Committee on Immunization Practices, the discussion about priority groups focused on essential workers, including health-care personnel. At the next meeting in August, the committee is planning to review considerations for other high-risk groups.
Workers at greatest risk for exposure to infectious diseases fall into six categories, according to a presentation by Sarah Mbaeyi, a medical officer at the CDC’s National Center for Immunization and Respiratory Diseases:
Health-care support (home health aides and medical assistants).
Health-care practitioners (doctors, dentists, nurses and pharmacists).
Protective service (police officers and firefighters).
Personal care and service (childcare workers, barbers and fitness trainers).
Community support (social workers, probation officers and health educators).
Education, training and library (K-12 teachers and librarians).
People of color are more likely to work in jobs deemed essential or with increased risk of disease exposure, she said.
She also provided greater detail about risks facing health-care personnel. The CDC uses a broad definition that includes people not involved in direct patient care: clerical, dietary, environmental services, laundry, security, maintenance, engineering and facilities management, administrative billing, and volunteer personnel.
Citing a recent study of risk for severe COVID-19 illness among health-care personnel, Mbaeyi said 39% have a high-risk medical condition or are older than 65. Those who work in support roles, such as medical assistants or home health aides, or others with less than a bachelor’s degree, have the highest rates of underlying conditions. These groups in general, she said, also have a higher proportion of workers who are African American, Latinx, uninsured or have lower incomes.
Consideration of race or ethnicity as a criteria for vaccine prioritization drew considerable discussion.
Jose Romero, a pediatric infectious-disease specialist at Arkansas Children’s Hospital Research Institute who chairs the CDC immunization committee, spoke of Black, Latino and Native American communities hit hard by COVID-19. The COVID-19 death toll is twice as high among people of color younger than 65 as for white Americans, according to a recent CDC report.
When more data about vaccine effectiveness in different groups becomes available, officials and experts may adjust recommendations, according to Nancy Messonnier, director of CDC’s National Center for Immunization and Respiratory Diseases.