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UPDATED // The original text has been amended to clarify those groups included in phase 1c.
An influential federal advisory group voted Sunday to recommend that the elderly and certain key workers be the next group of Americans to have access to limited doses of COVID-19 vaccine.
The Centers for Disease Control and Prevention (CDC) Advisory Committee on Immunization Practices (ACIP) voted 13-1 for the recommendation. This is based on ACIP’s initial recommendation on the groups that should be in the first wave of vaccinations, described as phase 1a.
ACIP has previously recommended that Phase 1a include US health workers, a group of about 21 million people and residents of long-term care units, a group of about 3 million.
On Sunday, ACIP said the next priority group, Phase 1b, should be what it called key frontline workers, a group of about 30 million, and adults aged 75 and over, a group of about 21 million. When overlapping between groups, phase 1b covers about 49 million people, according to the CDC.
Phase 1c would then include adults aged 65-74 (a group of approximately 32 million), adults aged 16 to 64 with high-risk medical conditions (a group of approximately 110 million), and essential workers who did not qualify for inclusion in phase 1b (a group of about 57 million). With the overlap, phase 1c would cover about 129 million.
This month, the FDA granted emergency use authorizations for two COVID-19 vaccines, one developed by Pfizer-BioNTech and another by Moderna. Other companies, including Johnson & Johnson, have advanced potential rival COVID-19 vaccines in the late stages of testing. To date, approximately 2.83 million doses of Pfizer COVID-19 vaccine have been distributed and 556,208 doses have been administered, according to the CDC.
But there is likely to be another period of months in which competition for limited doses of COVID-19 vaccine will trigger difficult decisions. Current estimates indicate that there will be enough supply to supply COVID-19 vaccines to 20 million people in December, 30 million people in January and 50 million people in February, said Nancy Messonnier, MD, director of the Center. National Center for Immunization and Respiration of CDC Diseases.
State governments and health systems will consider ACIP recommendations as they launch their initial COVID-19 vaccine reserves.
There is clearly a wide latitude in these decisions. Last week, for example, many members of Congress posted on Twitter photos of themselves receiving COVID-19 vaccines, despite not being included in the ACIP description of Phase 1.
Difficult choices
All ACIP members described Sunday’s vote as a difficult decision. It forced them to choose from segments of the US population that could benefit from early access to the limited supply of COVID-19 vaccines.
“For every group we add, it means we subtract one group. For every group we subtract, it means I don’t get the vaccine for a few months,” said ACIP member Helen Keipp Talbot, MD, of Vanderbilt University, Nashville. , Tennessee. “It’s incredibly humiliating and heartbreaking.”
ACIP member Henry Bernstein, DO, who voted the only vote against, said he agreed with most of the group’s recommendations. He said he fully supported the inclusion of adults aged 75 and older and key frontline workers in Phase 1b. But he voted no, because the data on COVID-19 morbidity and mortality for adults aged 65-74 are similar enough to the older group to justify their inclusion in the first wave.
“Therefore, including the 65- to 74-year-old group in Phase 1b made more sense to me,” said Bernstein, a professor of pediatrics at the Zucker School of Medicine at Hofstra / Northwell in New York.
As defined by the CDC, the key frontline workers included in Phase 1b will be those commonly referred to as the “first responders”, such as firefighters and police officers. Also in this group are teachers, support staff, childcare providers and those engaged in food and agriculture. Others in this group would include US postal service employees and workers in transit.
ACIP panelists noted the difficulties that will arise as government officials and health care leaders move to apply their guidance to real-world decisions regarding the distribution of limited supply of COVID-19 vaccine. There is a potential to exacerbate existing disparities in access to health care, as people with higher incomes may find it easier to obtain evidence that they qualify as having a high-risk condition, said José Romero, MD, president ACIP.
Many people do not have access to medical care and cannot come up with a doctor’s note that says, “I have diabetes,” he said.
ACIP panelists also noted in their deliberations that people can technically qualify for a priority group, but are at low risk, such as someone with a chronic condition who works from home.
And the risk for COVID-19 remains serious even for those who will eventually enter phase 2 for vaccination. Young adults have suffered serious complications from COVID-19, such as stroke, which can change their lives dramatically, said Talbot, a member of ACIP, adding that he is reminded of this in his work.
“We have to be very careful to say ‘young adults will be fine,'” she said. “I spent the past week with backup clinical calls and read these charts and cried every day.”
The three ACIP members who had conflicts that prevented them from voting were Robert L. Atmar, MD, who said at Saturday’s meeting that he participated in COVID-19 studies, including research on the Moderna vaccine; Sharon E. Frey, MD, who said at Saturday’s meeting that she was involved in research on COVID-19 vaccines, including Moderna; and Paul Hunter, MD, who said he received a grant from Pfizer for pneumococcal vaccines. The other members of the panel did not report any relevant financial statements.
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