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Healthcare workers and residents of long-term care facilities may be first in line to get the COVID-19 vaccine, followed by essential workers and then adults with high-risk medical conditions and older adults, members of the CDC's Advisory Committee on Immunization Practices (ACIP) agreed during a .

These new groups would be phase 1a, phase 1b, and phase 1c, respectively, with "gating criteria" to progress from one phase to the next. It would likely be similar to airlines' system for boarding aircraft -- with group 2 allowed to board even though some members of group 1 haven't shown up at the gate yet.

While there was no vote, ACIP members were largely supportive of this allocation strategy. The committee previously said it will hold an emergency meeting to vote on distribution after a particular vaccine receives approval or authorization from the FDA.

Nancy Messonnier, MD, director of the CDC's National Center for Immunization and Respiratory Diseases, estimated there will be 40 million vaccine doses available in December, enough for 20 million people to receive two doses, and then enough to immunize 25 million people each succeeding month.

Prioritizing which healthcare workers receive the vaccine first will be critical, as ACIP's chair, José Romero, MD, noted "front line" workers, or those with the highest risk of acquisition of disease, may also include "the housekeeping staff that has to quickly turn around rooms in the emergency department."

Discussion arose about prioritizing healthcare workers who do not have the ability to work from home. ACIP member Beth Bell, MD, of the University of Washington in Seattle, emphasized the importance of not necessarily having 100% coverage in every group, not even healthcare workers.

"We don't want to be in a situation where we're not using vaccine available to us as efficiently as possible," she said.

A brief discussion arose around including long-term care facility residents in phase 1a, with Helen Keipp Talbot, MD, of Vanderbilt University in Nashville, noting the high mortality rate in these facilities and the unfortunate probability that many residents will die despite vaccination.

She feared a "striking backlash," citing such hypotheticals as "my grandmother got the vaccine and she passed away" that may erode vaccine confidence early on. Talbot also pointed out that long-term care residents had not specifically been studied in randomized trials.

But most other members pointed to the disproportionately high burden of disease in this population, as well as the efficiency in vaccinating residents at the same time as facility staff.

"It's hard to get back to some locations from an infrastructure standpoint [and] it's a small enough population that I would be in favor of it," said Grace Lee, MD, of Stanford University.

ACIP members applauded putting essential workers in phase 1b, a decision that Kathleen Dooling, MD, of the CDC, said was based on the ACIP's recently released for allocating initial supply of COVID-19 vaccine. She added that vaccinating essential workers in phase 1b "strongly supports maximizing benefits and minimizing harms, [promoting] justice and [mitigating] health inequities."

"This is where we can really elevate the issue of health equity," said ACIP member Lynn Bahta, RN, of the Minnesota Department of Health. "An intersection between essential workers and the community is where we've seen the greatest amount of disease."

Dooling also referenced updated modeling data presented at the October meeting. When researchers assumed a vaccine efficacy of 90% in younger and older adults, they found there was no substantial difference in averted infections or deaths, regardless of which group received the vaccine next.

She noted the groups of eligible essential workers is determined by the Department of Homeland Security, and any given jurisdiction may choose to prioritize some workers over others.

Messonnier addressed the group at the end of the afternoon, applauding their diligence in going over these issues.

"There are no perfect decisions," she said. "ACIP has made many good recommendations that we at CDC have relied on for many years and I trust you ... to make the correct decision now."

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