LOUISVILLE, Ky. — By this time next month, one or more COVID-19 vaccines will likely be available. The federal government says 20 million people could be vaccinated against the deadly corovnaivus by the end of the year. But who will be the first (and second, and third) to get the shots?

What You Need To Know

  • Doses of a COVID-19 vaccine could begin arriving in states next month

  • The CDC is developing guidelines to address who should get the vaccine first

  • A consensus has emerged that frontline health workers should be at the top of the list

  • Priority will likely then go to the most vulnerable people who live and work in the most high-risk places

It’s a question that public health officials, bioethicists, and political leaders have grappled with for months. With confirmation last week that both the Pfizer and Moderna vaccines are more than 90% effective, it’s also more releavant now than ever. Official word on the protocol for distribution and prioritization is still weeks away, but here’s what we know now:

Why doses have to be prioritized

In an ideal world, there would be no need to prioritize recipients of the COVID-19 vaccine, but 2020 is anything but ideal. One thing that will help speed the process along is the relatively abundant supply of medicine that will be shipped around the country once the vaccine is improved. Last week, Health and Human Services Secretary Alex Azar estimated that 40 million doses of the Pfizer and Moderna vaccines will be available by the end of December, thanks to the efforts of Operation Warp Speed. Given the short lead time between development and distribution though, that’s an impressive number.

Since both vaccines require two shots, the 40 million doses will vaccine half as many people. Twenty million vaccinations is a great start, but it’s still just six percent of the U.S. population. That’s where the strategy comes in. 

Who decides

The first step in bringing the vaccine to the public is Emergency Use Authorization from the U.S. Food and Drug Administration (FDA), which Pfizer requested last week and Moderna is expected to request in the coming weeks. Once the FDA signs off, two things will happen. First, shipments to local distribution centers will begin. Then the Centers for Disease Control and Prevention (CDC) will step in.

“The CDC has the ultimate determination for the recommendations,”  Dr. Anthony Fauci said on CBS “Face the Nation” over the weekend. Those recommendations will not come through until the FDA has authorized the vaccines for emergency use though.

As a part of the CDC approval process, the Advisory Committee on Immunization Practices (ACIP) will produce a plan for who gets the vaccine first. What we know now is that the doses will be allocated to each state by population and that The National Academies of Sciences, Engineering, and Medicine (NASEM) has produced a “framework” to guide the ACIP.

Who goes first

The framework, along with most everyone else, says frontline healthcare workers should go first. From doctors and nurses to EMTs, these are the people who regularly come in contact with COVID patients, and giving them the vaccine first is no-brainer.

“Those frontline healthcare heros that are exposed to COVID-19 everyday I think we all agree are the first people who are going to need a safe vaccine,” Governor Andy Beshear said last month. 

From there, the pecking order is slightly less obvious. The NASEM suggests a phased approach with people who are at “significantly higher risk” due to underlying conditions and elderly people living in congregate settings coming next. Phase 2 of the plan includes vaccines for teachers, essential workers, the country’s entire elderly population, anyone with an underlying condition that puts them at “moderately higher risk,” and people living in homeless shelters, group homes, jails, and prisons. Phase 3 has young adults, children, and other workers important to “the functioning of society," while phase 4 includes everyone else.

The public debate over this framework is ongoing though. On Monday, ACIP held a meeting in which experts discussed issues such as where nursing home residents belong in the hierarchy of distribution. While it is a high risk group, elderly people were not included in trails and vaccines tend to not work as well on them. 

On its website, the CDC lays out in broader terms the goals that will be kept in mind as the prioritization list is created. The four goals are:

  • "Decrease death and serious disease as much as possible
  • Preserve functioning of society
  • Reduce the extra burden the disease is having on people already facing disparities
  • Increase the chance for everyone to enjoy health and well-being"

It also specifies the “ethical principles” guiding the process, which don’t just include the obvious minimization of viral transmission. The CDC will also attempt to “mitigate health inequities” and “promote justice,” two principles that could be used to ensure groups disproportionately affected by COVID-19 have higher priority in the race to get the vaccine. 

But theirs is not the only proposal. Teams from Johns Hopkins University and the World Health Organization have also mapped out prioritization proposals that are informing ACIP’s work. And others have suggested more novel approaches. Over the summer some public health officials suggested a weighted lottery, which would give everyone a shot at the vaccine, but some with a better chance than others. For example, people most likely to benefit from the vaccine or those in groups disproportionately hurt by the pandemic might have a greater chance to win the lottery. Proponents argue that this approach is more fair than others. 

Kentucky’s plan

Once the CDC releases its guidance it will be up to individual states to distribute the vaccine and they will have some latitude in how they do it. In October, Kentucky submitted its draft plan to the CDC. The preliminary report provided projections of who the Kentucky Department of Public Health (KDPH) will ultimate prioritize for vaccination and it hews closely to the framework released by NASEM, beginning with healthcare workers and vulnerable residents of assisted living facilities and moving to workers who play a “critical role in provision of health services.”

“Supplies of the vaccine will be limited, at first,” Dr. Steven Stack, commissioner of KDPH, said last month. “This is the reason for a phased distribution approach. As supplies of the vaccine rise, all Kentuckians are expected to have access.”

Whether they'll actually avail themselves of the vaccine is an open question though. Public polling suggests that only 58% of Americans will get vaccinated when they have the option. Roughly 70% is needed for herd immunity. 

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