Who should get the vaccine first? The debate over a CDC panel’s guidelines, explained.

Millions of doses of the Pfizer/BioNTech and Moderna vaccines against Covid-19 are being shipped around the United States right now, and millions more are on the way. But there are 330 million Americans, and according to expert estimates, it may be the summer or even the fall before everyone who wants the vaccine can get it.

So who gets to be vaccinated first?

That’s the question that the Advisory Committee on Immunization Practices (ACIP), a panel of medical and public policy experts that reports to the Centers for Disease Control and Prevention (CDC), tackled in its latest guidelines. Under the new guidelines from a meeting on December 20, health care workers and those in nursing homes will go first, followed by those 75 and older and front-line essential workers, followed by those 65 and older and other essential workers.

The panel had issued preliminary guidelines at the start of December; Sunday’s new guidelines saw ACIP revise some of its initial recommendations, which had come in for criticism (more on this below). ACIP’s guidance is aimed at informing states how to distribute the vaccine, but states don’t have to follow the panel’s recommendations — each one decides vaccine prioritization independently.

In the early December meeting of the ACIP and again at a December 11 meeting, the agency appeared to recommend, uncontroversially, that front-line health care workers and those in nursing homes be vaccinated first. But, much more controversially, the panel recommended that essential workers be vaccinated before people with high-risk medical conditions or people 65 and older.

The concern raised by critics about vaccinating essential workers before older adults is that it is projected that doing so would cause far more deaths than focusing on the elderly first. It was also a major departure from how other countries were prioritizing vaccination. (The ACIP explained that it recommended vaccinating essential workers over older people in part because of equity considerations — essential workers are more racially and socioeconomically diverse than elderly Americans.)

In the past week, that feature of the plan drew fire online. “Age needs to be a higher priority than pre-existing conditions in vaccine rollout plans. Or a lot of people are going to die, unnecessarily,” FiveThirtyEight political commentator Nate Silver argued on Twitter. In an article titled “Give the Vaccine to the Elderly,” policy writer and Vox co-founder Matt Yglesias argued that the ACIP was inappropriately “saying that racial equity considerations militate against prioritizing the elderly even though they concede that doing so would save the most lives of people of all races.”

Those critiques prompted their own backlash from the public health community. Yale epidemiologist and AIDS activist Gregg Gonsalves struck back at critics, arguing that political commentators have no understanding of the topics they’re opining on.

The new ACIP guidelines largely land on the side of the critics of the initial recommendations. But the argument among public policy experts, medical experts, ethicists, and others is likely not over, as each state will have to decide whether to take up the ACIP guidelines and how exactly to roll out its coronavirus vaccination program.

After a year of a devastating pandemic that has eroded trust in American institutions — often justifiably so — the debate over how to vaccinate everybody is actually a debate over something much bigger that’s played out over the past year: When should we trust experts and institutions, and when should non-experts and the public speak up and question decisions they disagree with?

The Advisory Committee on Immunization Practices guidelines, explained

There is virtually no disagreement among medical experts or their critics on whom we should vaccinate first: front-line health care workers and nursing home residents and staff.

A disproportionate share of coronavirus deaths are in nursing homes, which can be prevented as soon as vaccines are distributed. Meanwhile, health care workers are risking their lives for us, and, once they are vaccinated, hospitals are less likely to be overwhelmed with their staff out sick, which will in turn save more lives. There is consensus on these points, which are reflected in the ACIP guidelines.

It’s after that where things get complicated. In slides from the December 1 ACIP meeting, here’s how the panel proposed allocating the vaccines:

ACIP Presentation Slides: December 2020, Meeting/cdc.gov

After health care personnel and long-term care facility workers are vaccinated, the earlier guidelines proposed that the approximately 100 million essential workers be vaccinated before adults who are older than 65 or adults with high-risk medical conditions.

Saad Omer, director of the Yale Institute for Global Health, told my colleague Julia Belluz that this represented a major deviation from other international groups of experts.

“The reason everyone is prioritizing the elderly — compared to people 18 to 29 years of age — is that even at ages 65 to 74, they have a 90 times higher risk of death,” Omer told Belluz. “My hope is [ACIP] will revisit some of the assumptions that were driving the considerations for the trade-off between essential workers and older-age populations.”

Indeed, after a month that included spirited public debate and some intense criticism of the ACIP’s proposed prioritization, the panel made changes at its most recent meeting that put age closer to front and center. The guidelines released December 20 specify that phase 1b will include “persons aged ≥75 years and frontline essential workers,” and phase 1c will include “persons aged 65–74 years, persons aged 16–64 years with high-risk medical conditions, and other essential workers.” (Front-line essential workers include corrections officers, grocery store workers, teachers, and first responders.)

The change moves the ACIP closer in line with the recommendations from the World Health Organization (WHO) and the US National Academies of Sciences, Engineering, and Medicine (NASEM). Looking at other countries’ guidelines is also instructive. For instance, compared to the ACIP guidelines — even the revised ones — the United Kingdom’s vaccine guidelines are decidedly more focused on age. That’s because their scientists concluded that age was the simplest target, and saved the most lives and the most quality-adjusted life-years.

“Given the current epidemiological situation in the UK, all evidence indicates that the best option for preventing morbidity and mortality in the initial phase of the programme is to directly protect persons most at risk of morbidity and mortality,” a report from the Department of Health and Social Care on vaccine prioritization concludes.

As a result, the sequence of the United Kingdom’s vaccine rollout will go as follows:

1. Residents in a care home for older adults and their carers
2. All those 80 years of age and over and front-line health and social care workers
3. All those 75 years of age and over
4. All those 70 years of age and over and clinically extremely vulnerable individuals
5. All those 65 years of age and over
6. All individuals ages 16 years to 64 years with underlying health conditions that put them at higher risk of serious disease and mortality
7. All those 60 years of age and over
8. All those 55 years of age and over
9. All those 50 years of age and over

“It is estimated that taken together, these groups represent around 99% of preventable mortality from COVID-19,” the Joint Committee on Vaccination and Immunization report concludes.

This approach is broadly representative of the approach being taken in the rest of Europe, according to a report from the European Center for Disease Prevention and Control.

“Older age groups, healthcare workers and persons with underlying conditions are the most common target groups being considered by countries as priority groups for vaccination,” the center reported, summarizing the results of a survey among 31 member countries.

The big picture: How do we decide who gets vaccinated?

When the ACIP released the earlier draft of its proposed vaccine prioritization, which seemed to recommend favoring essential workers over older adults despite projecting that this approach would lead to more deaths, its approach drew criticism.

“I will be eternally perplexed if the US doesn’t choose to vaccinate the elderly first and foremost, along with those who take care of them directly,” wrote Zeynep Tufekci, a University of North Carolina professor of sociology who has emerged as one of the country’s sharpest coronavirus policy commentators. “Everyone deserves protection, but if we do not prioritize vaccination by actual risk, which basically means prioritizing by age and vaccinating the elderly first, it may well be the greatest, most consequential mistake [the] United States does in a year full of very very bad ones.”

She cited a preprint of a paper on vaccine prioritization, which makes the case that vaccinating older adults first will save the most lives. It would also save the most “life-years” — a measure of lives saved that considers how many more years of life that person has (and so values saving a 20-year-old much more than saving an 80-year-old).

Yglesias echoed that critique, chiming in that, based on slides from recent ACIP meetings, the panelists agreed that vaccinating elderly people ahead of essential workers would save the most lives. In light of that, Yglesias argued, the apparent recommendation for vaccinating essential workers ahead of elderly people seemed wrong. Furthermore, he pointed out, “essential workers” was a category certain to be subject to endless lobbying and wrangling that would likely end up favoring the privilege. Age, on the other hand, is hard to game.

Also in the chorus was New York Times opinion columnist Ross Douthat. Silver of FiveThirtyEight weighed in as well, writing that it “is completely indefensible that ACIP presents data like this showing that age is a FAR bigger risk factor for dying of COVID than pre-existing conditions & yet puts them on the same tier for vaccine prioritization.”

According to the preponderance of the current research, the coronavirus is simply so deadly to the elderly that getting them vaccinated is more effective than vaccinating younger people for a wide variety of policy goals. Even though older Americans are disproportionately white, vaccinating the elderly still ends up saving the most Black lives — because the virus is that fatal in that age category overall. Even though people with many other conditions are at increased risk from the virus, vaccinating older adults still does better than targeting those risk groups at saving lives.

And while vaccinating other groups might cut transmission more (if the vaccine does indeed block transmission), vaccinating the elderly also dramatically reduces the load on hospitals, which helps with the return to normal life and with saving the lives of others relying on medical care.

The flood of critical commentary angered some in the public health field, who felt that dragging the conversation about vaccination onto Twitter couldn’t be the best way to litigate it. Silver was accused of ignoring epidemiologists — even though epidemiologists also designed the WHO and NASEM prioritization approaches that Silver was advocating. Gonsalves expressed frustration at the criticism, noting that the ACIP was trying to account for many things: equity, reducing transmission by targeting people in public-facing roles, and reasonable national policy priorities like reopening schools as soon as possible.

The phrasing of some of the concerns about the ACIP’s prioritization can certainly be objected to; there was absolutely needless snark. But in the substance of their concerns, Tufekci and others ended up being vindicated — as reflected in the latest revised set of ACIP prioritization guidelines, which put the elderly higher up the list, as the critics had called for.

Debates over Covid-19 and vaccines can be frustrating — but they’re part of a democratic process

It’s easy to understand why members of the public health community bristled at the critical commentary from non-experts. After all, it’s been a hard year, one in which public health expertise has essentially been polarized by the president. Any new critiques can seem like more needless piling-on.

But the criticisms above are a part of a healthy process — and, if anything, we need more such open and engaged debate. (The fact that ACIP moved toward the critics’ position certainly suggests that those critics weren’t out of line.)

Rationing health care is inherently a tragic and awful thing to do. It invites ethical trade-offs of enormous complexity, and there’s a long history of the US government doing it wrong, such as prioritizing kidney transplants only to churchgoing middle-class men. Open public critique and engagement is an important part of the process by which a healthy democracy figures out how to solve hard moral dilemmas. Even if it would be wise to defer more to experts on the science, no one in this debate actually disagreed on the science. Rather, the debate was over the public policy implications of that science — and ethics is not a field best left to the experts. If public buy-in is needed, public discussion should be welcomed.

Moreover, 2020 has challenged narratives that the people in charge will get it right and that it will never be productive for outsiders to argue with them. Public criticisms helped persuade the CDC to adopt mask guidelines. Public figures including Tufekci have played a major role in steering America toward better coronavirus policy on topics from outdoor activities to mask-wearing to ventilation. Yes, experts have played an indispensable role in the fight against coronavirus — but insightful public commentators who have questioned policy where it seemed shaky have undoubtedly helped in this fight.

I’m sure some of the distrust directed at hardworking public health officials and scientists stings, and no doubt much of it is undeserved, aimed at people who have done a great job with scandalously limited resources. But it’s a bad idea to ask people arguing in good faith to keep skeptical or dissenting views to themselves — especially in a case like this where they were pointing out a real shortcoming in the ACIP’s plans and where broader moral considerations that we’re all implicated in were in play.

Trust is won through what the ACIP actually did — a revision of a previous position that better tracked the science about how to save as many lives as possible. And in a period where public trust in the country’s institutions is at a low ebb, experts’ sincere engagement with public concerns and honest critics can only help win back that trust.

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