Adults, ages 75 and older, and “frontline essential workers” should receive the COVID-19 vaccine in phase 1b, the CDC Advisory Committee on Immunization Practices (ACIP) said Sunday.
In a 13-1 vote, the ACIP voted for an interim recommendation for phase 1b and phase 1c of COVID-19 vaccination. Phase 1c is comprised of adults 65-74, adults 16-64 with high-risk medical conditions, and all other essential workers.
Frontline essential workers are defined as first responders, education, food and agriculture, manufacturing, corrections workers, U.S. Postal Service workers, public transit workers, and grocery store workers, according to the Cybersecurity and Infrastructure Security Agency (CISA). A frontline essential worker is someone in a sector essential to the functioning of society and are at “substantially higher risk of exposure to SARS-CoV-2.”
“This is without a doubt the hardest vote I have taken in my 6-and-a-half years on the committee,” said ACIP Chair Jose Romero, MD. Many committee members also expressed concern and upset at the idea of allocating COVID-19 vaccines, and said they hope that vaccine supply will improve so that all who want a vaccine can get it.
Henry Bernstein, DO, of Zucker School of Medicine at Hofstra/Northwell Cohen Children’s Medical Center in New Hyde Park, New York, was the lone dissenter, saying while he was supportive of phase 1b, he felt the science around COVID-19 morbidity and mortality and “the inclusion of the 65 and older group in phase 1b made more sense to me.”
Other committee members noted the number of adults, ages 65 and older, would exceed the amount of vaccine available when phase 1b is scheduled to roll out.
Adults, ages 75 and older, were not initially in phase 1b when ACIP met to discuss allocation recommendations in late November, but CDC staff noted this group accounts for 25% of COVID-19-associated hospitalizations, and risk of in-hospital death from COVID-19 increased with age.
When looking at frontline essential workers, they noted jurisdictions may choose to vaccinate those living in congregate settings, such as prisoners and people in homeless shelters, in phase 1b (similar to how long-term care facility residents are being vaccinated along with healthcare workers in phase 1a).
Non-frontline essential workers who were recommended for phase 1c included those in transportation and logistics, food service, construction, finance, information technology and communication, energy, media, legal, and public safety, as well as waste and wastewater.
There was little debate over phase 1b, but some committee members objected to the broadness of phase 1c, expressing concern that some younger non-frontline essential workers might be vaccinated before older adults with higher COVID-19 morbidity and mortality.
Pablo Sanchez, MD, of the Research Institute at Nationwide Children’s Hospital in Columbus, Ohio, said he wanted to see older frontline workers, ages 65-74, moved ahead of the younger frontline workers or even adults who had retired.
Nancy Messonnier, MD, director of CDC National Center of Immunization and Respiratory Diseases, said guidance for subprioritzation within the groups would be addressed in the clinical considerations, “with the hopes that at least being able to articulate the rationale” to decide “who gets in front and who gets in back.”
As always, recommendations from ACIP are not considered final until they are published in the Morbidity and Mortality Weekly Report (MMWR), which CDC staff said should happen this week. They added ACIP may hold another meeting between now and its regularly scheduled meeting in February, likely on additional COVID-19 vaccines.
Moderna Green Light; Anaphylaxis Update
ACIP held another meeting Saturday, where the committee voted 11-0, with three abstentions due to conflicts of interest, to recommend the Moderna COVID-19 vaccine for adults, ages 18 and older, under the terms of the FDA emergency use authorization (EUA). FDA issued an EUA for the Moderna vaccine late Friday, making it the second vaccine to be authorized.
This interim recommendation is now official with publication in MMWR on Sunday.
CDC staff also provided an update on cases of anaphylaxis and severe allergic reactions associated with the Pfizer/BioNTech vaccine. As of December 18, there were six cases under investigation meeting Brighton Collaboration criteria for anaphylaxis. These case reports are undergoing clinical case review by CISA, they said. One case had a history of anaphylaxis following rabies vaccination.
There was no geographic pattern to these incidents, so CDC staff said it is unlikely to be related to a specific vaccine production lot. CDC staff confirmed all cases were in adults younger than age 65, but offered no further details.
They pointed to the clinical considerations document about anaphylaxis and COVID-19 vaccination, although committee members suggested that may need to be reevaluated once vaccination in “other settings” starts.