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How the government decides who should get vaccinated first

Authorities have to consider which groups are most at-risk of developing severe COVID-19, as well as which groups can do the most to protect others.

2,925 doses of the Pfizer COVID-19 vaccine
FedEx delivery driver Seth Warnecke delivered a box containing 2,925 doses of the Pfizer COVID-19 vaccine to the Minneapolis VA Hospital on Monday morning. At left, VA director Patrick Kelly and Gov. Tim Walz look on.
Aaron Lavinsky/Star Tribune/Pool

This week, the first shipments of COVID-19 vaccine are arriving in Minnesota.

It’s a big deal. In the nine months since the COVID-19 pandemic began, more than 386,000 Minnesotans have had confirmed cases of the virus, and nearly 4,600 have died of it.

With a vaccine comes hope that not only the deaths will stop, but that life will return to normal again at some point in the not-so-distant future. For that to happen, though, a sizable share of the state’s 5.6 million residents will need to be vaccinated against the virus.

There won’t be enough vaccines for everyone right away. This month, health officials expect to receive roughly 183,000 doses of vaccine.

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Who gets to decide who gets vaccinated first, and how are those decisions made?

In the United States, the Centers for Disease Control’s Advisory Committee on Immunization Practices (ACIP) is responsible for making recommendations about how all vaccines, including those designed to fight COVID-19, should be distributed. With limited initial supply, the ACIP followed  frameworks from the National Academy of Sciences (NAS) and others to weigh the practical and ethical concerns about distributing the vaccine and develop guidelines about how to do so equitably.

Complicated considerations

In making these decisions, people apply longstanding and complex ideas about what justice is, what’s right or wrong, and the duties of doctors toward their patients to the situation at hand, said Joel Wu, an adjunct professor at the University of Minnesota’s Center for Bioethics.

“One of the key considerations is whether or not the allocation actually maximizes the opportunity for people to be healthy and reduces the risk that people are going to be sick and not be able to get better,” he said.

That can look different based on the disease: For example, the 1918 flu pandemic hit young adults particularly hard, with roughly half of the deaths occurring among people between the ages of 20 and 40. There was no flu-fighting vaccine at the time of the 1918 pandemic, but if there had been, the groups prioritized for getting it would likely have looked different than those for COVID-19, which is much deadlier for older adults.

The NAS framework and others consider how ethical principles interact with the epidemiology of the novel coronavirus to determine who should get the vaccine, when.

vaccination phases
National Academy of Sciences Framework for Equitable Allocation of COVID-19 Vaccine
In the case of NAS’, there are four recommended phases. The first includes those working in high-risk settings, older adults living in congregate settings and those with underlying health conditions that put them at a much higher risk of getting sick from the virus. NAS reasoned that this group includes the people most likely to be severely affected by COVID-19 and those who are most essential to ensuring the health of the population.

Second, NAS suggested vaccinating essential workers, like teachers, those in industries essential to the functioning of society, people in crowded living situations and those in group homes and homeless shelters, with the rationale that these people have a vital role in society, or are at greater risk of getting sick due to underlying health conditions or their living situation.

Third comes young adults and children, who NAS noted are less likely to become severely ill from COVID-19 but often have broad social networks or other situations that make them a risk for transmission to others. (No vaccine has been approved for use in children under age 16, though kids are being added to trials so more data is likely to come soon. Another factor that could affect where children and young adults fit in the vaccine queue is how effective the vaccines are at stopping transmission of the virus.)

As of now, data show the Pfizer and Moderna vaccines are very effective at decreasing the development of severe COVID-19, so vaccine recommendations tend to prioritize populations at risk of developing severe disease. Researchers are still trying to determine how well the vaccines affect transmissibility (though new data suggest the Moderna vaccine may also be effective at preventing transmission).

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The fourth phase of vaccination includes anyone who didn’t have access to the vaccine previously.

In an effort to promote equity in the face of health inequalities, NAS also suggested using a Social Vulnerability Index to determine priorities across different phases. The index takes into account inequality attached to demographic factors like race and poverty and is designed to get vaccine more quickly to people more likely to be severely affected by COVID-19 due to these socioeconomic factors.

Immunizing for impact

Minnesota is following the recommendations set by the ACIP, but so far, the committee has only finalized its recommendations about the first group of people who will get the vaccine: called “1a,” it’s a subgroup of the first phase that includes health care workers and those living and working in long-term care.

The 183,000 initial doses of vaccine headed for Minnesota won’t cover the 500,000 people estimated to be in group 1a. So the Minnesota Department of Health convened its own advisory committee to make sub-prioritizations.

“Our goal is to immunize for impact. We want to make sure that we’re vaccinating where it will do the most good,” MDH Infectious Disease Director Kris Ehresmann said in a briefing on state vaccination plans last week.

Within group 1a, MDH’s Vaccine Allocation Advisory workgroup created the following priorities:

  • First: Health care workers in COVID-19-designated units and urgent care clinics, emergency departments, skilled nursing facility and nursing home employees and residents, EMS personnel, COVID-19 testers and COVID-19 community vaccinators.
  • Second: Hospital, urgent care and dialysis center workers in direct patient care or those handling infectious materials, and assisted living facility residents and workers.
  • Third: Health care workers not in the first two groups who can’t work from home, and adults in residential care facilities such as those that serve people with intellectual and physical disabilities and adult foster care.

“The goal of immunizing for impact is really to not just get vaccine in the arms of people, but really focusing in on what populations or what arms provide multiplier benefits,” said Dr. Jill Amsberry of the Minnesota Medical Association, who is on the MDH COVID-19 Vaccine Allocation Advisory Group.

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Vaccinating health care workers has a multiplier effect because this group ensures access to health care for the sick, Amsberry said: lately, many health care workers have been out sick or home because of exposures to COVID-19, creating capacity problems with high numbers of COVID-19 patients in hospitals.

Decision makers also considered that health care workers are among the most likely to trust the science behind the vaccine, which means a high proportion of them will be willing to get vaccinated.

Those living and working in long-term care also qualify as members of the first 1a priority group because they are the most likely to be severely affected by COVID-19: 65 percent of deaths in the state have been among residents of long-term care or assisted living, according to data from MDH.

“Those individuals are getting sick and dying at alarming rates,” Amsberry said. “As they are the most affected by the disease it makes sense to focus on that population.”

There’s also a multiplier effect here in that long-term care residents are among the most likely to land in the hospital with COVID-19, so vaccinating them may reduce hospitalizations and help free up health care resources, for COVID-19 care as well as to start up procedures that were delayed due to staffing or capacity issues.

Difficult decisions to come

Because it’s pretty clear which groups are hardest-hit by COVID-19 and which workers are critical for keeping the health care system going, there was fairly broad consensus over who should get the first doses of vaccines, Amsberry said.

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When officials make decisions about who’s vaccinated in later groups, they’ll use the same ethical and practical considerations. But the determinations to come, such as who is considered an essential worker and in what order such workers are prioritized may be more complicated. Already, different professions are jockeying to get their workers ahead in the lineup: should teachers go before farmers? Should grocery store workers go before those in manufacturing?

“In some ways the more challenging conversations are yet to come,” Amsberry said.