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A new report that aims to prioritize groups to receive Covid-19 vaccine focuses on who is at risk, rather than using job categories or ethnic groups to determine who should be at the front of the line.

It was widely expected that health care workers would be the first priority grouping, and some — though not all — are. There were also many voices arguing for people of color to be given priority access, because the pandemic has exacted a disproportionately heavy toll on Black and Latinx people, both in terms of overall numbers of infections and deaths.

But in the end the panel of experts that wrote the priority setting framework for the National Academies of Sciences, Engineering, and Medicine chose instead to focus on the factors that create the risk for some people of color — systemic racism that leads to higher levels of poor health and socioeconomic factors such as working in jobs that cannot be done from home or living in crowded settings. The report, a draft, was issued Tuesday.

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“This virus has no sense of skin color. But it can exploit vulnerabilities,” said Bill Foege, a former director of the Centers for Disease Control, who is co-chair of the committee. The committee was set up by the National Academies at the request of Francis Collins, director of the National Institutes of Health, and Robert Redfield, director of the Centers for Disease Control and Prevention.

Foege said he expects pushback. A virtual public meeting on the recommendations will be held Wednesday afternoon, and written comments can be submitted until Friday. The committee’s final report will be submitted later in September.

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When Covid-19 vaccines are approved for use, initial supplies will be tight — potentially in the tens of millions of doses. Most of the vaccines under development will require two doses per person: a priming dose followed by a booster either three or four weeks later.

Phase graphic
A phased approach outlined in the draft National Academy report. The National Academies of Sciences, Engineering and Medicine

The resulting recommendations put health workers in high risk settings and first responders to the very front of the vaccination line, in what the committee called the “jumpstart phase.” Closely behind are adults of any age who have medical conditions that put them at significantly higher risk of having severe disease, primarily heart or kidney failure or a body mass index of 40 and over. Also in this group are older adults living in long-term care homes or other crowded settings.

The report suggests that a second phase of vaccinations should involve critical risk workers — people in industries essential to the functioning of society — as well as teachers and school staff; people of all ages with an underlying health problem that moderately increases the risk of severe Covid-19; all older adults not vaccinated in the first phase; people in homeless shelters and group homes, and prisons; and staff working in these facilities.

Young adults, children, and workers in essential industries not vaccinated previously would make up the third priority group. Remaining Americans who were not vaccinated in the first three groups would be offered vaccine during a fourth and final phase.

The report is meant to serve as a guide for more detailed prioritization plans on the order in which Americans will be offered vaccine. That more granular work is already being conducted by the Advisory Committee on Immunization Practices, an expert panel that crafts vaccination guidance for the CDC, and by state, local, and tribal health authorities, who must identify the actual people in their regions who fall into the priority groups.

The ACIP’s recommendations will go to the CDC. It remains unclear, however, whether the CDC, Operation Warp Speed — the task force set up to fast-track development of Covid-19 vaccines, drugs, and diagnostics — or the White House will make the final determinations on who will be vaccinated first.

The draft report, produced in just a little over a month, earned some early praise.

“I think they did a really good job,” said Eric Toner of the Johns Hopkins Center for Global Security, calling the report credible and based on sound reasoning.

Toner and colleagues published their own report on the issue recently, recommending two tiers. Health workers and others essential to the Covid-19 response in the first tier and other health workers in the second.

In that report, people at greatest risk and their caregivers, and workers most essential to maintaining core societal functions would also be designated to be in the first tier.

The task of determining who should be at the front of the vaccines line is not an easy one, and must be made without crucial pieces of information. It’s not yet known how many vaccines will prove to be successful, when they will be approved for use, and in what quantities. Critically, some vaccines may prove to be more effective in key groups — the elderly, for instance — than others. Knowing that in advance could influence the recommendations, but people working on the priority groups cannot wait for that information to become available.

Initial discussions suggest, depending on how some of the target groups are defined, large numbers of Americans would qualify as members of priority groups, a reality that will likely require additional tough decisions to be made.

The CDC estimates that there are between 17 million and 20 million health care workers in the country, and roughly 100 million people with medical conditions that put them at increased risk of severe illness if they contract Covid-19. There are roughly 53 million Americans aged 65 and older, and 100 million people in jobs designated as essential services. There is some overlap among these groups — health workers, for instance, are also essential workers.

  • I understand health care workers are very important, but the difference in prognosis for say a 25 year old nurse, a woman with no known risk factors, vs. a 65 year old man in OK health but with normal American chronic conditions, seems to be, the nurse is 50 to 100 times better off than the old guy – she has 1 in 1,000 chance of serious disease – or maybe 1 in 2,000 – and the old guy has 1 in 10 or 1 in 20.

    • Steve,
      I’m a 40-something healthy physician and completely agree with you. Even though I interact with COVID patients, I’m low risk if I were to fall ill. I’m very provax but am not comfortable taking this vaccine until it completes a proper phase 3 trial and follow up assessments of its efficacy a few months later. It doesn’t seem ethical to give me the vaccine because a) I don’t want it right now and feel I’m being forced into a phase 4 trial without my consent and b) the injection should be given to someone in a high risk group who could suffer greatly if they get infected. I hope that the powers that be agree with your thoughts. I sure do!

  • You can be certain the if Trump wins reelection, the first in line to receive any new COVID-19 vaccine would be friends of and donors to Trump. He would simply take the chart from this article and add “friends of and donors to Trump” with his personal sharpie marker” as Phase before Phase 1.

  • Almost a 100% recovery rate, so other than profit for the pharmaceutical companies, why do we need a vaccine?

    • Wow. I love “Lauren” the pharma troll has to wish a disease on someone. Nice! She trounced on my comment too. I was making a point that this vaccine has NOT been tested on children at all. Dr. Offitt from CHOP in Pennsylvania has repeatedly stated this vaccine should NOT be given to children for several years because vaccines for adults don’t translate to safe for children. Who said anything about autism? For the record, my children are grown so I’m saying I won’t be taking it or be bullied into it either. I’m not selfish but I should be able to decline having someone injected into my bloodstream without being made to feel guilty about it.

  • There are efforts underway to stratify according to risk of developing significant disease post-infection based on an individual’s “omic” profile (primarily genes and proteins). If those work soon, would make more sense to use that info than lumping people together by social, ethnic or chronological statuses.

  • Why are children even on this list? Even Dr. Offitt has stated this vaccine would need to be tested in children and it will take years for this to be done. I will be steering clear of this one!

    • Quelle suprise! Go ahead and send your poor kids out to acquire “herd immunity”. Now if you don’t want to get the vaccine before the Phase 3 trials are completed and analyzed by scientists and clinicians, I don’t blame you. With Trump trying to ram this through so he can claim “he” found the vaccine before the election, I won’t listen to him or Dr. Atlas.
      Fact: There is NO correlation between autism and vaccines. Period.

    • I’m sure the phase timing is subject to change. We may not trigger phase 3 for a couple years. That doesn’t mean this isn’t “over” well before then. All this talk of vaccinating 320MM Americans is silly. It isn’t happening and it isn’t going to stop us from getting back to “normal” either.
      Kids simply are not impacted by the virus in any great manner. Yes, there are absolutely tragic stories but those are clearly exceptions. Kids may not get the first vaccines because they don’t necessarily need one.

    • Lauren – you’re addressing things nobody in the comments is even saying.
      But please, tell us how everybody else is being political.

  • This may be an unusual instance of advance planning during this crisis, or another instance of greasing the skids to get vaccine approved. (I don’t blame the writer for a faithful presentation.) That said there are crucial items missing as Ms Braswell notes. “Critically, some vaccines may prove to be more effective in key groups — the elderly, for instance — than others. Knowing that in advance could influence the recommendations,”

  • Personally, I’d like to see teachers (including day care) moved up in priority so schools can safely resume. (I’m 68 years old so, even though I hate it, I can stay safely in my home without economic/health hardship.)

  • There should be a group tasked with identifying segments of the population that will resist vaccination, how large these groups will be, how significant this might be in hobbling efforts to stop the spread of the disease, how some of these people might be persuaded of the importance of vaccination, etc. There is an anti-vaccination movement significantly large to cause problems with childhood diseases, so it could definitely become an issue.

    • I agree. I’m not at all worried about the plan who receives the vaccine first. What’s the plan for the people who refuse the vaccine to stop the pandemic to be able to move on from this?

    • I get my annual flu shot, tetanus booster every 10 years. I am a senior who is at risk for Covid. I am not an anti-vaxer. However, I do not intend to get the vaccine until it has proven to be safe. My father was a physician who was convinced his sister died as a result of aggressive swine flu inoculations in the 70s. Better safe than sorry.

    • Lynne, I’m sure there are 10’s of millions of people thinking exactly the same thing. But, how will we know when the vaccine is safe? The front runners in the vaccine race have phase 3 trials involving 10’s of thousands of people scheduled to run through October 2021. So that’s at least a year. And even then, that’s a pretty small sample compared to 330 million US citizens. Will some rare adverse events show up three or four years later? Maybe. More importantly, the risk of getting the disease and suffering a bad outcome (even death) must be weighed against the risk of an adverse vaccine event. Personally, I would rather risk the vaccine than the disease. If offered a chance to enroll in a phase 3 trial, I would do it. I think the vaccine will be safer than contracting the disease. But I certainly understand a lot of people may want to wait years to see if the vaccine is really safe. And I do think that is going to be a problem in controlling COVID-19.

    • We’re not vaccinating 320MM Americans nor are we vaccinating 7B people. You might get to half that. Once you take care of the vulnerable populations and people stop dying in hospitals we’ll move past this. Most people clear the virus with little difficulty and the vaccinated vulnerable are protected.

    • Doug M – they are doing Phase 3 trials on at least two vaccines and adding one soon- go on clinicaltrials.gov and see if you qualify – but REMEMBER – there is only a 50% chance you will get a real vaccine- so the rule is, stay safe even afterwards – but it might save your life and it is research which needs doing.

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