For more information: www.cdc.gov/COVID19

COVID-19 vaccine prioritization: 

Work Group considerations

Kathleen Dooling, MD MPH

August 26, 2020

ACIP COVID-19 Vaccines Work Group
 Ensure safety and effectiveness of COVID-19 vaccines

 Reduce transmission, morbidity, mortality of COVID-19 disease

 Help minimize disruption to society and economy, including maintaining healthcare 

capacity

 Ensure equity in vaccine allocation and distribution

Work Group Considerations: 

Goals of the COVID-19 Vaccine Program
Identifying groups for allocation of initial doses COVID-19 vaccine:

critical for program planning

Strengthen vaccine distribution 

networks to reach target groups

Develop state and local microplans 

for vaccine implementation

Create communications strategies to 

promote vaccination in target groups

Plan evaluations to rapidly 

monitor vaccine safety, 

effectiveness, and coverage

3

Engage partners 

and stakeholders
Administration of COVID-19 vaccine will require a phased approach

Limited Doses Available Large Number of Doses Available Continued Vaccination

Volume

doses

available

(per month)

Key

factors

Likely 

admin

strategies

• Constrained supply

• Cold chain & handling may require specialized 

equipment and high throughput

• Likely sufficient supply to meet demand

• Additional vaccine products allow a wider range 

of administration locations

• Sufficient supply to meet demand

• Highly targeted administration • Broad administration network required 

(pharmacies, doctors offices, public health 

clinics, mobile clinics, FQHCs)

• Focus on increasing access for critical 

populations

•Harness vaccine provider networks with 

proven ability to reach critical 

populations

• Enhance series completion
Administration of COVID-19 vaccine will require a phased approach

Limited Doses Available Large Number of Doses Available Continued Vaccination

Volume

doses

available

(per month)

Key

factors

Likely 

admin

strategies

• Constrained supply

• Cold chain & handling may require specialized 

equipment and high throughput

• Likely sufficient supply to meet demand

• Additional vaccine products allow a wider range 

of administration locations

• Sufficient supply to meet demand

• Highly targeted administration • Broad administration network required 

(pharmacies, doctors offices, public health 

clinics, mobile clinics, FQHCs)

• Focus on increasing access for critical 

populations

•Harness vaccine provider networks with 

proven ability to reach critical 

populations

• Enhance series completion

Projected short period of time 

for when doses are limited 
Proposed scenarios for planning for D&A initial phase 

(Q4 2020)

Does not represent decisions; preliminary scenarios for planning

Scenario Cumulative Doses 

available Distribution requirements Administration 

1. Vaccine candidate A 

is the first to demonstrate 

safety & efficacy

• Shipped direct at --70-80oC on dry 

ice, to be used within 10 days

• Vaccine can be stored at 2-8oC for 24 hours

• 6 hour shelf life at room temperature

• Unique diluent / kit requirements

• Only shippable to large admin sites

2. Vaccine candidate B

is the first to demonstrate 

safety & efficacy

• Central distro capacity at -20oC,

may be stored for months at -20oC

• Vaccine can be stored at 2-8oC for 7 days

• 6 hour shelf life at room temperature 

3. Vaccine candidates A and B

demonstrate safety & efficacy • As above

• Administration site considerations as above

• Complexity increases significantly if sites are 

administering 2 products with different 

requirements and differing dose schedules
 Microplanning

 Critical population focus

 Federal entity planning

 Development of IT tools

 Communications and engagement materials

CDC Activities to Support Implementation Planning
Meeting

June  Support for identification of groups for allocation of initial vaccine to aid 

implementation planning

 Recognition of disparity in COVID-19 impact on race/ethnic groups, 

essential workers, low income families, etc.

 Need to build on existing vaccine infrastructure to meet challenges of 

the COVID-19 vaccination

July  Support for healthcare personnel and other essential workers to 

receive initial vaccine allocation 

Recap of ACIP discussions early phase COVID-19 vaccination
 Describe the group

 Estimate the size

 Consider implementation 

challenges

 Healthcare personnel

 Essential workers

 Persons with high risk medical conditions

 Older adults (≥65 years)

Objective for today’s ACIP discussion:

Focus on the Work Group’s proposed groups for 

early phase vaccination

September:

Possible vote on 

interim allocation of 

initial vaccine doses

ACIP considerations for 

sequence of groups
Estimated 

Population

Examples:

 Hospitals

 Long term care facilities 

(assisted living facilities & 

skilled nursing facilities)

 Outpatient 

 Home health care

 Pharmacies

 EMS

 Public health

 All paid and unpaid persons serving in healthcare 

settings who have the potential for direct or 

indirect exposure to patients or infectious 

materials

 Includes persons not directly involved in patient 

care but potentially exposed to infectious agents 

while working in a healthcare setting

Healthcare personnel

https://www.bls.gov/ooh/healthcare/home.htm

~17-20M
Composition of healthcare workforce varies widely by setting

https://datausa.io/profile/naics/hospitals https://datausa.io/profile/naics/nursing-care-facilities

Hospitals

Skilled 

Nursing 

Facilities

11
Estimated 

Population

Examples:

 Food & Agriculture

 Transportation

 Education

 Energy

 Water and Wastewater

 Law Enforcement

 Workers who are essential to continue critical 

infrastructure and maintain the services and 

functions Americans depend on daily

 Workers who cannot perform their duties remotely 

and must work in close proximity to others should 

be been prioritized

 Sub-categories of essential workers may be 

prioritized differently in different jurisdictions 

depending on local needs

Essential Workers 

(non Healthcare)

https://www.cisa.gov/publication/guidance-essential-critical-infrastructure-workforce

~60-80M
Healthcare personnel and essential worker race/ethnic 

composition is similar to U.S. population (self-report, NHIS)

National Health Interview Survey (NHIS) details – data from 2016, 2017 and 2018, Analysis: Modeling Section, COVID-19 Response, CDC
Hispanic and non-White workers accounted for 73% of 

workplace outbreak-associated COVID-19 cases in Utah

Bui DP, McCaffrey K, Friedrichs M, et al. Racial and Ethnic Disparities Among COVID-19 Cases in Workplace Outbreaks by Industry Sector — Utah, March 6–June 5, 2020. 

MMWR Morb Mortal Wkly Rep 2020;69:1133–1138. DOI: http://dx.doi.org/10.15585/mmwr.mm6933e3
Estimated 

Population

Examplesǂ % Population

 Obesity 31%

 Diabetes 11%

 COPD 7%

 Heart Condition 7%

 Chronic kidney 3%

 Cancer

 Chronic kidney disease

 Chronic obstructive pulmonary disease (COPD)

 Immunocompromised state from solid organ transplant

 Obesity (BMI of 30 or greater)

 Serious heart conditions (heart failure, coronary artery 

disease or cardiomyopathies)

 Sickle cell disease

 Type 2 diabetes mellitus

Adults with medical conditions at 

higher risk for severe COVID-19*

* https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/people-with-medical-conditions.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-

ncov%2Fneed-extra-precautions%2Fgroups-at-higher-risk.html

ǂ https://www.cdc.gov/mmwr/volumes/69/wr/mm6929a1.htm?s_cid=mm6929a1_w

>100M
Estimated 

Population

 16% of the U.S. 

population

 ~3M person live in 

long-term care facilities

Adults 65 years and older

United States Census Bureau https://www.census.gov/topics/population/older-aging.html

https://www.cdc.gov/nchs/fastats/nursing-home-care.htm

~53M

Population in Millions
The proportion with COVID-19 high risk medical conditions is 

similar among younger and older adults (NHIS, self-report)

33% 39%

National Health Interview Survey (NHIS) details – data from 2016, 2017 and 2018, Analysis: Modeling Section, COVID-19 Response, CDC
 Overlapping

 Significant heterogeneity

 Accounts for > half of 

U.S. adults

 Need for additional 

sub-grouping

Summary: Groups for early 

phase vaccination

Healthcare 

personnel 

~17-20M

Essential workers

~60-80M

High Risk Medical Conditions

>100M

Adults ≥ 65 years old

~53M
Work Group Considerations

Epidemiology, Feasibility of Implementation, Equity & Ethics 
 A COVID-19 vaccine that requires distribution and storage at -20oC, followed by 7 

days (max) at 2-8oC, will require diligent vaccine management to minimize waste

 The storage, distribution and handling requirements of a -70oC vaccine will make it 

very difficult for community clinics and local pharmacies to store and administer 

 will necessitate most vaccine be administered at centralized sites with 

adequate equipment and high throughput

 vaccinating healthcare personnel at centralized sites with high throughput is 

the best allocation of initial supply

Work Group Interpretation: Implementation challenges & 

implications for distribution of initial vaccine
 Workers at long-term care facilities are a priority among healthcare personnel and 

achieving high coverage is important and may be resource intensive

 Mass vaccination clinics will be difficult to conduct in the setting of social distancing.

 Healthcare homes, such as provider offices or pharmacies, could be better suited to 

provide vaccination if recommendations are based on individual risk factors such as 

age or underlying medical conditions. 

 Challenges to equitable vaccine administration:

– Reaching rural areas

– Racial and ethnic minorities

– Populations with limited access to vaccines

Work Group Interpretation: Implementation challenges & 

implications for distribution of initial vaccine
Key Unknowns: 

 Vaccine performance: the magnitude of benefits and potential 

risks, for younger and older adults

 Possibility of multiple vaccines with differing profiles

 The pathway to approval: emergency use authorization or full 

licensure

 The timing of vaccine availability

 The number of doses available and rate of scale-up 

Identifying groups for interim prioritization of initial 

COVID-19 vaccine

22

Importance of identifying 

priority groups

Strengthen 

distribution 

networks

Create 

communication 

strategies

Develop state/ 

local microplans

Implement safety and 

effectiveness 

evaluations
 Review clinical trial data for candidate vaccines, as they become available

– Safety data, including plans for post-approval safety surveillance

– Immunogenicity and efficacy data

 Review epidemiologic data for risk of COVID-19 disease and severity by race/ethnicity

 Review results of focus groups and other public engagement regarding COVID-19 

vaccines

 Review equity frameworks for allocating vaccine

Next Steps for the COVID-19 Vaccine Work Group:

Develop and vote on an interim prioritization schema for initial 

COVID-19 vaccine
Tier 1: 

 Those most essential in sustaining the ongoing COVID-19 

response

 Those at greatest risk of severe illness and death, and their 

caregivers

 Those most essential to maintaining core societal functions

Tier 2:

 Those involved in broader health provision

 Those who face greater barriers to access care if they 

become seriously ill

 Those contributing to maintenance of core societal functions

 Those whose living or working conditions give them elevated 

risk of infection, even if they have lesser or unknown risk of 

severe illness and death

Interim Framework for COVID-19 Vaccine Allocation and 

Distribution in the United States

https://www.centerforhealthsecurity.org/our-work/publications/interim-framework-for-covid-19-vaccine-allocation-and-distribution-in-the-us 24

“The purpose of this report is 

to offer an ethics framework 

that can be used to make 

decisions about the allocation 

of a SARS-CoV-2 vaccine during 

the initial period of scarcity in 

the United States and make 

related suggestions about 

vaccine distribution.” 
1) Given the information presented 

thus far (epidemiology, values, 

acceptability, feasibility) do you agree 

that initial doses of COVID-19 vaccine 

should be allocated to healthcare 

personnel?

2) If supply remains constrained, due 

to vaccine or distribution limitations, 

do you agree with vaccinating 

essential workers next as supply 

permits?

Questions:

Healthcare 

personnel 

~17-20M

Essential workers

~60-80M

High Risk Medical Conditions

>100M

Adults ≥ 65 years old

~53M
1) Given the information presented 

thus far (epidemiology, values, 

acceptability, feasibility) do you agree 

that initial doses of COVID-19 vaccine 

should be allocated to healthcare 

personnel?

2) If supply remains constrained, due 

to vaccine or distribution limitations, 

do you agree with vaccinating 

essential workers next as supply 

permits?

Questions:

Healthcare 

personnel 

~17-20M

Essential workers

~60-80M

High Risk Medical Conditions

>100M

Adults ≥ 65 years old

~53M
Background slides
Safety is paramount. Vaccine safety standards will not be compromised in 

efforts to accelerate COVID-19 vaccine development or distribution

Inclusive clinical trials. Study participants should reflect groups at risk for 

COVID-19 to ensure safety and efficacy data are generalizable

Efficient Distribution. During a pandemic, efficient, expeditious and 

equitable distribution and administration of approved vaccine is critical

Flexibility. Within national guidelines, state and local jurisdictions should have 

flexibility to administer vaccine based on local epidemiology and demand

ACIP COVID-19 Vaccine Work Group: Proposed Guiding Principles

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