A Centers for Disease Control and Prevention (CDC) advisory panel has designated frontline essential workers and those age 75 years and older as the next priority groups to receive COVID-19 vaccine in the United States.

The decision came amid considerable criticism and controversy at an emergency meeting on Dec. 20, 2020, with the CDC Advisory Committee on Immunization Practices (ACIP) voting to continue the rationing process while vaccine stocks are insufficient.1

“We are faced with the situation, at least in the short term, where we have a limited supply of vaccine available to us,” said Nancy Messonnier, MD, director of CDC’s National Center for Immunization and Respiratory Diseases. “What that means is that there will be difficult choices about who gets that vaccine first.”2

Eventually, there should be adequate supplies for national vaccination. In the interim, ACIP has held some agonizing debates on the benefits and risks of choosing which group should be immunized before another.

“These are difficult decisions,” said ACIP member Sharon Frey, MD, of Saint Louis (MO) University Medical School. “There are no perfect recommendations. People will continue to become ill with this disease and die from [it] until there is adequate vaccine.”

ACIP has drawn criticism for not reaching out enough to minority communities, as well as showing bias against white people by making its most recent selection “essential frontline workers” ahead of all people aged 65 to 74. At the meeting, ACIP Chairman José Romero, MD, addressed this issue openly in a statement he read before the full committee.

“[There has been] disinformation and statements made to impugn and undermine the work that the ACIP has carried out over these last nine months — and more specifically, over the last two months — that has caused doubt among the American public as to our motives and decisions,” he said. “It has been said that our recommendations are excluding specific racial groups. It is important that the public understands that throughout the long period of deliberations, thoughtful discussions, and careful evaluation of the data, the ACIP has struggled painfully to deal with distribution of a limited resource of vaccines. Our attempt has been always to achieve equitable, ethical, and fair distribution of that resource. We have never targeted a specific ethnic nor racial group for receipt of the vaccine. All of our decisions and recommendations for the priority groups take into account the burden of disease within those groups. And within those groups, white, Caucasian individuals predominate. The statements being made and carried by various outlets undermine the careful work that we have provided, and undermine the trust of the American public in our committee. I want to emphasize again: We have never focused on any particular racial group in coming to our recommendations.”3

Priority Groups Designated

Given limited supplies and ongoing distribution challenges, ACIP is recommending priority groups receive the vaccine based on medical and ethical models to provide the greatest societal benefit. CDC recommendations are not mandatory, but represent the best ACIP consensus recommendations to state and local health officials administering the vaccines.

As an update to the recent 1a recommendations to vaccinate healthcare workers, including those in long-term care, and residents of nursing homes, ACIP designated the next priority groups for immunization while vaccine supplies are limited as follows. The estimated total population in each group is listed in parentheses:

1b: Persons age 75 years and older (21 million) and frontline essential workers (30 million). The latter group includes first responders, firefighters, police, teachers, food and agriculture, manufacturing, corrections workers, postal workers, public transit, and grocery store workers.

1c: Persons age 65 to 74 years (32 million); persons age 16 to 64 years with high-risk medical conditions like heart disease and diabetes (110 million); and other essential workers (37 million). The latter group includes transportation, food service, construction, finance, communications, energy, media, legal, public safety engineers, and water and wastewater.

With many critics saying the 65 to 74 age group should be prioritized over younger frontline essential workers, several states shifted the vaccination groups to do just that after the ACIP guidelines were released.

One aim of immunizing essential frontline workers rather than a larger group of the elderly is “preservation of societal functioning,” ACIP meeting materials indicate. As approved, the recommendations essentially call for vaccinating a large frail population as well as one subjected to frequent exposures in the community.

“Persons 75 years and older represent 8% of the population, 25% of hospitalizations, and have a very high death rate,” said ACIP member Katherine Poehling, MD, MPH, of Wake Forest School of Medicine in Winston-Salem, NC. “Frontline essential workers have high exposure. They include a disproportionate share of racial and ethnic persons who also have a disproportionate share of hospitalizations.”3

However, one ACIP member, Henry Bernstein, DO, of the Zucker School of Medicine at Hofstra/Northwell, voted against the recommendation.

“I am in full support of [vaccinating] persons 75 and older and frontline essential workers being in phase 1b,” he said at the meeting. “However, I voted no because I feel that the science regarding COVID-19 morbidity and mortality supports notable similarities between the 65- and 74-year-old group and the 75 years and older group. Therefore, inclusion of the 65- to 74-year-old group in phase 1b made more sense to me. I also believe overall implementation of this unprecedented, complex national vaccination would be simplified by doing so.”3

A Difficult Choice

Even some members who voted to approve the aforementioned priority groups expressed consternation about bypassing the 65-74 age group.

“I really want to reiterate my concern,” said ACIP member Pablo Sanchez, MD, of Nationwide Children’s Hospital in Columbus, OH. “I feel strongly that the elderly and those with high-risk medical conditions really should be up front over some potential workers who may be younger.”3

Several ACIP members said it was the most difficult vote during their tenure on the advisory panel. “For every group that we add, we need to subtract a group,” said ACIP member Helen Talbot, MD, MPH, of Vanderbilt University. “For every group that we subtract, they don’t get the vaccine. It has been very humbling and heartbreaking.”3

In approving the recommendation, the committee was “trying to thread the needle,” said ACIP member Peter Szilagyi, MD, MPH, of UCLA Health.

“I voted for this recommendation because, in my opinion, it follows the evidence about the risk of coronavirus and the ethical principles that we have developed at ACIP to maximize benefits and minimize harm, and to mitigate health inequity,” he said.3

ACIP member Grace Lee, MD, of Stanford University, said the panel’s goal is to provide safe and effective vaccines for the entire population. In working toward this aim, vaccines can bring unity and hope to people.

“However, we have seen vaccines become used as a tool for disinformation, fears about allocation, and division within our communities,” she said. “We are currently prioritizing vaccine to people at the greatest risk of infections due to their occupation, such as frontline healthcare workers, providers, and essential workers; and those of greatest risk of hospitalizations and deaths, such as long-term care facility residents, older adults, and those with underlying conditions. These priorities reflect the racial, ethnic, and the socioeconomic diversity of the U.S. population.”3

Still, many public comments submitted to ACIP were critical of the decision to immunize frontline essential workers before those age 65 to 74 years.

“As a physician who has treated COVID cases and a concerned citizen, I want to state that the ACIP guidelines are not well thought through and contain extremely dubious claims,” commented Vikram Vaz, MD, a radiologist in Houston. “Continuing to prioritize essential workers — many of whom are younger and at lower risk than the elderly or immunocompromised — will directly result in the avoidable deaths of tens of thousands [of] Americans of all races.”4

In additional guidance and clarification issued after the ACIP meeting, the CDC said adults of any age with “certain underlying medical conditions are at increased risk for severe illness from the virus that causes COVID-19 and can be immunized with the approved mRNA COVID-19 vaccine provided they have not had a severe allergic reaction to any of the ingredients in the vaccine.”5

This includes people with HIV and those with weakened immunity due to other illnesses or medication. However, they should be aware of the limited vaccine safety data, the CDC emphasized.

“People with weakened immune systems should also be aware of the potential for reduced immune responses to the vaccine, as well as the need to continue following all current guidance to protect themselves against COVID-19,” the CDC noted.

According to the CDC, people with autoimmune conditions or those who were previously diagnosed with Guillain-Barré syndrome may receive an mRNA COVID-19 vaccine. Again, they should be aware of the dearth of vaccine clinical trial data in weighing the risk and benefits.

“Cases of Bell’s palsy were reported in participants in the mRNA COVID-19 vaccine clinical trials,” the CDC noted. “However, the FDA does not consider these to be above the rate expected in the general population. They have not concluded these cases were caused by vaccination. Therefore, persons who have previously had Bell’s palsy may receive an mRNA COVID-19 vaccine.”

REFERENCES

  1. Centers for Disease Control and Prevention. Advisory Committee on Immunization Practices Dec. 20, 2020, meeting recommendations. https://www.cdc.gov/vaccines/acip/index.html
  2. Feuer W. CDC panel says frontline essential workers, people 75 years and older should get COVID vaccine next. CNBC. Dec. 20, 2020. https://www.cnbc.com/2020/12/20/cdc-panel-says-frontline-essential-workers-people-75-years-and-older-should-get-covid-vaccine-next.html
  3. Centers for Disease Control and Prevention. Dec. 20, 2020, ACIP meeting: ACIP vote. https://www.youtube.com/watch?v=pPElO2dBqmU&amp%3Bab_channel=CentersforDiseaseControlandPrevention%28CDC%29
  4. Centers for Disease Control and Prevention. Dec. 20, 2020, ACIP meeting: Public comment. https://www.youtube.com/watch?v=VaUaluoqpo8&amp%3Bab_channel=CentersforDiseaseControlandPrevention%28CDC%29
  5. Centers for Disease Control and Prevention. COVID-19 vaccination considerations for persons with underlying medical conditions. Updated Dec. 29, 2020. https://www.cdc.gov/coronavirus/2019-ncov/vaccines/recommendations/underlying-conditions.html