For more information: www.cdc.gov/COVID19

Phase 1 allocation COVID-19 vaccine: 

Work Group considerations

Kathleen Dooling, MD MPH

September 22, 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
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

Work Group Considerations: Proposed Guiding Principles

E

Q

U

I

T

Y
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, central distribution

• 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

Phase 1a: Healthcare personnel

Phase 1b may include: Essential Workers, 

High risk Medical Conditions, Adults 65+

• 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 
Possible groups for Phase 1 vaccination 

Healthcare 

personnel 

~20M

Essential workers

~80M

High Risk Medical Conditions

>100M

Adults ≥ 65 years old

~53M

August ACIP meeting

Phase 1a:

-HCP

Phase 1b:

-Essential Workers

-High Risk Med Conditions

-Adults ≥ 65 years old

September ACIP meeting

-Explore groups for phase 1b

-risk for COVID-19

-overlap between groups

-racial and ethnic composition

-Summary of Work Group 

considerations
Healthcare 

personnel 

~20M

Essential workers

~80M

High Risk Medical Conditions

>100M

Adults ≥ 65 years old

~53M

Questions:

1) If constrained vaccine 

supply necessitates 

sequencing of groups in 

Phase 1b, what are the most 

important information gaps 

we need to fill for ACIP to 

make sequencing 

recommendations? 

2) What is the correct balance 

of national guidance and 

local flexibility?
Phase 1a: Healthcare personnel
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

Estimated ~17 

Population -20M
Healthcare personnel: Summary of Work Group Considerations

EQUITY VALUES FEASIBILITY ACCEPTABILITY BENEFITS 

& HARMS

Support

-↑ representation of 

some racial minority 

groups in subsets of 

HCPs

-LTCF

-home healthcare

-HCPS included as early 

phase group in all valuesbased allocation 

frameworks considered

-Large health systems have 

occupational health depts to 

facilitate vaccine clinics

-May have -80C freezers

-Moderate/high rates 

of influenza vaccine 

acceptance.

-high scientific literacy

?

Challenge

-Rural and LTCF, small clinics, 

home healthcare workers 

may be difficult to reach

?
Phase 1b: Essential workers (non-healthcare)
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

~60M
Essential Workers (non-healthcare): COVID-19 Risk

 By July 2020, 23 states reported outbreaks in 239 meat or poultry processing 

plants, resulting in ~16,000 cases in workers1

–

–

9% of workers diagnosed as cases by May (range =3%-25%)

 By mid-September, Corrections and Detention Facilities reported ~126,000 

cases in residents and ~27,000 cases in staff2

In an analysis of 16 U.S. prisons and jails, 56% identified their first case of COVID-19 among 

staff members as opposed to incarcerated/detained persons3

 In NYC, seroprevalence among Correctional facilities workers and Fire 

Department workers exceeded that of the general population4

1. MMWR July 10, 2020 https://www.cdc.gov/mmwr/volumes/69/wr/mm6927e2.htm?s_cid=mm6927e2_w

2. UCLA COVID-19 Behind Bars Data Project 

https://law.ucla.edu/academics/centers/criminal-justice-program/ucla-covid-19-behind-bars-data-project

3. Hagan et al. MMWR – projected publication date August 7. Results of Mass Testing for SARS-CoV-2 in 16 Prisons and Jails—

Six U.S. Jurisdictions, April–May 2020

4. https://www.cdc.gov/vaccines/acip/meetings/downloads/slides-2020-07/COVID-06-Oliver-508.pdf
Overlap: Essential Worker & High-Risk Medical Conditions

Essential 

workers

Obesity

(BMI>30)

~30%

Diabetes

~7%

CVD

~4%

CKD

~2%

Cancer

~4%

COPD

~3%
Selected essential industries by high risk medical conditions 

0

5

10

15

20

25

30

35

40

45

50

Grocery,

convenience, and

drug stores

Food manufacturing Transit, postal,

messengers, and

couriers

Trucking

Percent Prevalence among Industry Workers

Cancer

Coronary heart

disease

Chronic kidney

disease

COPD

Diabetes

Obesity (BMI≥30 

kg/m2)

https://www.cdc.gov/mmwr/volumes/69/wr/mm6936a3.htm?s_cid=mm6936a3_w
Racial and Ethnic minorities in selected essential industries

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

Rail

Transportation

Pharmacies &

Drug Stores

Truck

Transportation

Supermarkets &

Other Grocery

Stores

Child Day Care

Services

Postal Service Community Food

& Housing,

Emergency

Services

Grocery & Related

Product Merchant

Wholesalers

Individual &

Family Services

Bus Service &

Urban Transit

Services to

Buildings &

Dwellings

Source: American Community Survey. CEPRs Analysis of American Community Survey, https://cepr.net/a-basic-demographic-profile-of-workers-in-frontline-industries/
Racial and Ethnic minorities in selected essential industries

Source: American Community Survey. CEPRs Analysis of American Community Survey, https://cepr.net/a-basic-demographic-profile-of-workers-in-frontline-industries/

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

40.0%

45.0%

All Workers All Frontline

Industries

Grocery,

Convenience, &

Drug Stores

Public Transit Trucking,

Warehouse, &

Postal Service

Building Cleaning

Services

Childcare & Social

Services

Black Hispanic AAPI Other
~23% of essential workers live in low-income families 

(income <2X poverty line)

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

40.0%

45.0%

Public Transit Trucking, Warehouse &

Postal Service

Child Care & Social

Services

Grocery, Convenience &

Drug Stores

Building Cleaning

Services

Source: American Community Survey. CEPRs Analysis of American Community Survey, https://cepr.net/a-basic-demographic-profile-of-workers-in-frontline-industries/
~10% of essential workers have no health insurance

Source: American Community Survey. CEPRs Analysis of American Community Survey, https://cepr.net/a-basic-demographic-profile-of-workers-in-frontline-industries/

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

Public Transit Child Care and Social

Services

Grocery, Convenience

& Drug Stores

Trucking, Warehouse &

Postal Service

Building Cleaning

Services
Overlap: essential workers and adults ≥65 years

Healthcare 

personnel 

~20M

Essential workers

~80M

High Risk Medical Conditions

>100M

Adults ≥ 65 years old

~53M

~16% of essential workers 

are ≥65 years old or live 

with someone who is

Source: American Community Survey. CEPRs Analysis of American Community Survey, https://cepr.net/a-basic-demographic-profile-of-workers-in-frontline-industries/
Essential Workers: Summary of Work Group Considerations

EQUITY VALUES FEASIBILITY ACCEPTABILITY BENEFITS 

& HARMS

Support

↑ representation of 

racial and ethnic 

minority groups overall 

and within some 

essential industries

decisions

-Allocation frameworks all 

recognize essential workers 

as early phase vaccine 

recipients

-Mobile workers

-Mobile PODS may be 

deployed to worksites

-States will have to make 

prioritization decisions 

(flexibility)

- ?

Challenge

-Allocation frameworks are 

not aligned regarding the 

specific industries in phase I 

vs. phase II

-States will have to make 

prioritization decisions 

(workload, potential for 

policy differences State to 

State)

?

Unknown

How do workers in 

individual industries value 

COVID-19 vaccination?

What is acceptability 

of COVID-19 vaccine 

among essential 

workers?
Phase 1b: High risk medical conditions
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
 Nearly 90% of hospitalized adults had at least one high risk medical condition, and 

over 60% had 3 or more1

 Obesity, chronic kidney disease, diabetes and hypertension are associated with 

hospitalization for COVID-192

 Among hospitalized COVID-19 patients, the adjusted rate ratios for underlying 

medical conditions association with death ranged from 1.19 (diabetes) to 1.39 

(immunosuppression)3

High risk medical conditions: COVID-19 risk

1. https://gis.cdc.gov/grasp/COVIDNet/COVID19_5.html

2. Ko et al. Clinical Infectious Diseases, ciaa1419, https://doi.org/10.1093/cid/ciaa1419

3. Kim et al, Clinical Infectious Diseases, ciaa1012, https://doi.org/10.1093/cid/ciaa1012
29

0

10

20

30

40

50

60

Cancer Chronic kidney

disease

Cardiovascular

disease

Diabetes Obesity (BMI>30)

Crude Percentages

White

Black

American Indian/ Alaska Native

Asian

Hispanic/ Latino

Prevalence of selected underlying conditions that increase risk 

for severe COVID-19 disease, by race and ethnicity

Estimates were not available for Hawaiian/other Pacific Islanders or for chronic kidney disease among American Indian/Alaska Native 

Source: National Center for Health Statistics, National Health Interview Survey, 2018
High Risk Medical Conditions: Summary of Work Group Considerations

EQUITY VALUES FEASIBILITY ACCEPTABILITY BENEFITS 

& HARMS

Support

↑ prevalence of 

diabetes and obesity 

among racial and ethnic 

minority groups 

Allocation frameworks all 

support persons with 

high risk medical 

conditions as early phase 

vaccine recipients

-population with diagnosed 

medical conditions often 

connected with healthcare

-Moderate influenza 

vaccine coverage ?

Challenge

-diagnosis of condition 

may require access to 

healthcare

->100M group will require subprioritization

-high degree of overlap 

between obesity and DM2

-difficult to assess medical 

eligibility in mass vaccination 

clinics

?

Unknown

How do adults with high 

risk medical conditions 

value COVID-19 

vaccination?

What is acceptability 

of COVID-19 vaccine 

among persons with 

high risk medical 

conditions?
Phase 1b: Adults ≥65 years
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
 Adults 65 years and older represent 16% of COVID-19 cases but nearly 80% of 

COVID-19 deaths1

 Adults 65 years and older have the highest cumulative rate of COVID-19 associated 

hospitalizations2

 Older age is the strongest independent risk factor for in-hospital death3

Adults 65 years and older: COVID-19 Risk

1. https://www.cdc.gov/covid-data-tracker/index.html#demographics

2. https://gis.cdc.gov/grasp/COVIDNet/COVID19_3.html

3. Kim et al, Clinical Infectious Diseases, ciaa1012, https://doi.org/10.1093/cid/ciaa1012
Population 65 years and older by race and ethnicity

Race or Ethnicity Total Population 65 yrs and older

Hispanic or Latino 17.8% 8.0%

Not Hispanic or Latino 82.2% 92.0%

White 61.1% 77.3%

Black 12.3% 8.9%

AI/AN 0.7% 0.5%

Asian 5.4% 4.2%

NH/PI 0.2% 0.1%

Two or more races 2.4% 0.9%

https://www.census.gov/library/publications/2018/acs/acs-38.html
Overlap: Adults ≥ 65 years & High Risk Medical Conditions

Healthcare 

personnel 

~20M

Essential workers

~80M

High Risk Medical Conditions

>100M

Adults ≥ 65 years old

~53M

~39% of adults ≥ 65 years old 

have a high-risk medical 

condition for severe COVID-19

National Health Interview Survey (NHIS) details – data from 2016, 2017 and 2018, Analysis: Modeling Section, COVID-19 Response, CDC
Adults ≥65 years: Summary of Work Group Considerations

EQUITY VALUES FEASIBILITY ACCEPTABILITY BENEFITS 

& HARMS

Support

Allocation frameworks 

support early vaccination of 

older persons, especially 

those living in congregate 

settings

-good healthcare access 

through Medicare

-high proportion with a 

healthcare/pharmacy home

-Moderate influenza 

vaccine coverage ?

Challenge

Racial and ethnic 

minority groups underrepresented among 

adults ≥65 years

National Academies: older 

adults living at home, 

without high risk conditions, 

for Phase II vaccination

-mobility and ability to 

attend a mass vaccination 

clinic may be impaired for 

some

?

Unknown

How do adults ≥65 years 

value COVID-19 vaccination?

What is acceptability 

of COVID-19 vaccine 

among adults ≥65 

years?
Key Unknowns 

 Vaccine characteristics

–

–

–

–

–

Magnitude and balance of benefits and potential risks

Storage/distribution/handling cold chain requirements

Vaccine efficacy/immunogenicity in younger and older adult

 The pathway to approval

Emergency Use Authorization (all adults vs younger adults)

Licensure

 The number of doses available at time of approval and rate of scale-up 
Work Group Considerations: Next Steps

 Continue to build scientific understanding

–

–

–

–

–

–

–

epidemiology of the outbreak and risk in Phase 1 groups

modeling the impact of various vaccination strategies

interpretation of clinical trials safety data and plans for post-market safety monitoring

 Prepare Evidence to Recommendation Framework (EtR) for vaccines in 

Phase III clinical trials

prepare an equity domain to add to the EtR

gather evidence on value and acceptability of COVID-19 vaccine

once data are available from Phase III, GRADE safety and efficacy

prepare policy options for ACIP consideration
Healthcare 

personnel 

~20M

Essential workers

~80M

High Risk Medical Conditions

>100M

Adults ≥ 65 years old

~53M

Questions:

1) If constrained vaccine 

supply necessitates 

sequencing of groups in 

Phase 1b, what are the most 

important information gaps 

we need to fill for ACIP to 

make sequencing 

recommendations? 

2) What is the correct balance 

of national guidance and 

local flexibility?
Healthcare 

personnel 

~20M

Essential workers

~80M

High Risk Medical Conditions

>100M

Adults ≥ 65 years old

~53M

Questions:

1) If constrained vaccine 

supply necessitates 

sequencing of groups in 

Phase 1b, what are the most 

important information gaps 

we need to fill for ACIP to 

make sequencing 

recommendations? 

2) What is the correct balance 

of national guidance and 

local flexibility?