On December 1, the Advisory Committee on Immunization Practices (ACIP) recommended that health care personnel and long-term care facility residents be offered COVID-19 vaccination first (Phase 1a).
On December 20, ACIP updated interim vaccine allocation recommendations. In Phase 1b, COVID-19 vaccine should be offered to persons aged ≥75 years and non–health care frontline essential workers, and in Phase 1c, to persons aged 65–74 years, persons aged 16–64 years with high-risk medical conditions, and essential workers not included in Phase 1b.
Federal, state, and local jurisdictions should use this guidance for COVID-19 vaccination program planning and implementation.
The first vaccines for prevention of coronavirus disease 2019 (COVID-19) in the United States were authorized for emergency use by the Food and Drug Administration (FDA) (1) and recommended by the Advisory Committee on Immunization Practices (ACIP) in December 2020. However, demand for COVID-19 vaccines is expected to exceed supply during the first months of the national COVID-19 vaccination program. ACIP advises CDC on population groups and circumstances for vaccine use. On December 1, ACIP recommended that
1) health care personnel and
2) residents of long-term care facilities be offered COVID-19 vaccination first, in Phase 1a of the vaccination program. On December 20, 2020, ACIP recommended that in Phase 1b, vaccine should be offered to persons aged ≥75 years and frontline essential workers (non–health care workers), and that in Phase 1c, persons aged 65–74 years, persons aged 16–64 years with high-risk medical conditions, and essential workers not recommended for vaccination in Phase 1b should be offered vaccine.
These recommendations for phased allocation provide guidance for federal, state, and local jurisdictions while vaccine supply is limited. In its deliberations, ACIP considered scientific evidence regarding COVID-19 epidemiology, ethical principles, and vaccination program implementation considerations. ACIP’s recommendations for COVID-19 vaccine allocation are interim and might be updated based on changes in conditions of FDA Emergency Use Authorization, FDA authorization for new COVID-19 vaccines, changes in vaccine supply, or changes in COVID-19 epidemiology.
Phase 1b
Approximately 49 million persons, including frontline essential workers (non–healthcare workers) and persons aged ≥75 years are recommended to receive vaccine in Phase 1b of the COVID-19 vaccination program. Essential workers perform duties across critical infrastructure sectors and maintain the services and functions that U.S. residents depend on daily. The Cybersecurity and Infrastructure Security Agency (CISA) of the U.S. Department of Homeland Security has developed a list intended to guide jurisdictions in identifying essential critical infrastructure workers, who may be exempted during stay-at-home-orders.
ACIP used CISA guidance to define frontline essential workers as the subset of essential workers likely at highest risk for work-related exposure to SARS-CoV-2, the virus that causes COVID-19, because their work-related duties must be performed on-site and involve being in close proximity (<6 feet) to the public or to coworkers. ACIP has classified the following non–health care essential workers as frontline workers: first responders (e.g., firefighters and police officers), corrections officers, food and agricultural workers, U.S. Postal Service workers, manufacturing workers, grocery store workers, public transit workers, and those who work in the education sector (teachers and support staff members) as well as child care workers. A tiered approach for essential workers builds on the occupations identified by the National Academies of Science, Engineering and Medicine for early vaccination.
Although there is no national surveillance for COVID-19 among frontline or other essential workers, reports of high incidence and outbreaks within multiple critical infrastructure sectors illustrate the COVID-19 risk in these populations and the disproportionate impact of COVID-19 on workers who belong to racial and ethnic minority groups.
Persons aged ≥75 years are at high risk for COVID-19–associated morbidity and mortality. As of December 20, 2020, the cumulative incidence of COVID-19 among persons in this age group was 3,839 per 100,000 persons, with a cumulative hospitalization rate of 1,211 per 100,000, and a mortality rate of 719 per 100,000. The overall proportion of persons aged ≥75 years who live in a multigenerational household is 6%; the proportion among non-Hispanic White persons is 4%, and the proportion among racial or ethnic minority groups is higher (non-Hispanic Black persons, 10%; Hispanic or Latino persons, 18%; non-Hispanic persons of other races, 20
Phase 1c
In Phase 1c, vaccine should be offered to persons aged 65–74 years, persons aged 16–64 years with medical conditions that increase the risk for severe COVID-19, and essential workers not previously included in Phase 1a or 1b. Approximately 129 million persons are included in Phase 1c, accounting for the overlap between groups in Phase 1c and earlier phases; for example, some adults aged 65–74 years reside in long-term care facilities, and many essential workers have high-risk medical conditions. Persons aged 65–74 years are at high risk for COVID-19–associated morbidity and mortality. As of December 20, 2020, the cumulative COVID-19 incidence in this age group was 3,109 per 100,000 persons, with a cumulative hospitalization rate of 642 per 100,000, and a mortality rate of 188 per 100,000.
ACIP’s ethical principles for allocating initial supplies of COVID-19 vaccine, namely, to maximize benefits and minimize harms, promote justice, and mitigate health inequities (11), support the allocation scheme for Phases 1b and 1c. Allocation of COVID-19 vaccine to essential workers and persons at increased risk for severe COVID-19 disease balances the vaccination program priorities of minimizing societal disruption and preventing morbidity and mortality. Essential workers constitute a large and heterogenous group. Allocation of vaccine to frontline essential workers in Phase 1b acknowledges their increased risk for occupational exposure compared with other essential worker categories, as well as the benefits to society of maintaining these essential functions. Allocation to persons aged ≥75 years is supported by their high risk for COVID-19–associated morbidity and mortality and is anticipated to also reduce hospitalizations in this group, easing the burden on strained health care systems. Populations included in Phase 1c are either at an increased risk for severe COVID-19 compared with the general population or support ongoing critical infrastructure operations. In addition, certain essential worker groups have high proportions of some racial and ethnic minority groups who have experienced disproportionate COVID-19 incidence, morbidity, and mortality.
Implementing vaccination programs to reach essential workers will pose challenges. Use of multiple strategies is recommended to reduce barriers to vaccination, such as providing vaccination opportunities at or close to the workplace. State and local health authorities will need to take local COVID-19 epidemiology and demand for vaccine into account when deciding to proceed to the next phase or to subprioritize within an allocation phase if necessary. A flexible approach to allocation will facilitate efficient management and ensure that COVID-19 vaccine is administered equitably and without delay.
Phase 2
Phase 2 includes all other persons aged ≥16 years not already recommended for vaccination in Phases 1a, 1b, or 1c. Currently, in accordance with recommended age and conditions of use, any authorized COVID-19 vaccine may be used. ACIP is closely monitoring clinical trials in children and adolescents and will consider recommendations for use when a COVID-19 vaccine is authorized for use in persons aged <16 years.
