Grocery store employees, teachers, emergency workers, and other people on the front lines of America’s workforce should be next to get the coronavirus vaccine, along with adults ages 75 and older, a federal advisory panel said Sunday.

The recommendations, which came two days after regulators authorized a second coronavirus vaccine, will guide state authorities in deciding who should have priority to receive limited doses of shots made by Pfizer-BioNTech and Moderna. More than 2.8 million doses of the Pfizer vaccine have been distributed, and 556,208 of those shots were given as of 2 p.m. Sunday, according to the Centers for Disease Control and Prevention.

The groups designated Sunday to include about 49 million people, some of whom could begin getting shots early in the new year. The priorities represent a compromise between the desire to shield people most likely to catch and transmit the virus, because they cannot socially distance or work from home, and the effort to protect people who are most prone to serious complications and death.

Crews pack up doses of Moderna vaccine for nationwide distribution
Trucks with shipments of the second coronavirus vaccine by Moderna shipped out to all 50 states on Dec. 20. (The Washington Post)

An estimated 30 million front-line essential workers are laboring in meat plants, grocery stores, prisons, public transit, and other key areas, and cannot work remotely. They are a priority because they play a critical role in keeping society functioning, and they live or work in high-risk, high-transmission communities.

Adults 75 and older — about 19 million people — were also included in this priority group, because they account for 25 percent of hospitalizations and a significant share of deaths from covid-19, the disease caused by the coronavirus.

The Advisory Committee on Immunization Practices voted 13 to 1 to recommend these workers and older adults are prioritized in what is known as Phase 1b.

That decision arrived on the same day the first doses of Moderna’s vaccine began shipping out, along with the second wave of shipments from Pfizer, together destined for more than 3,700 locations. The shot can’t come soon enough for a nation experiencing a surge of coronavirus cases and covid-19 deaths, with more than 317,000 people succumbing since the start of the pandemic.

The committee’s vote also addressed an even larger group of people poised to gain access in the third phase. That larger group of 129 million people — part of Phase 1c — is made up of the second tier of essential workers, adults 65 to 74 and adults 16 to 64 with high-risk medical conditions.

The subsequent tier of essential workers represents 10 broad areas, including finance, information technology, food service, energy and transportation, and logistics.

But the desire to expand the pool of people receiving vaccinations collides with the reality that doses are limited. Federal officials anticipate having enough doses to vaccinate a total of 100 million people by the end of February.

The priority groups advanced on Sunday exceed the number of shots government officials expect to be available in the first months of 2021. In December, officials have said there are only enough doses to give 20 million people the first shot. The Pfizer and Moderna vaccines each require two doses.

In January, the anticipated supply will be enough for another 30 million people, with an added 50 million accounted for in February, Nancy Messonnier, a top CDC official, told the group Sunday, citing projections from the Trump administration’s Operation Warp Speed.

Advisory group members made clear that the broad outlines will give states flexibility to make priority decisions locally. States will probably move through the phases at different speeds. Decisions on moving to the next phase of vaccination are up to states, and they will depend on demand and the details of local vaccine rollout.

“These are going to be imperfect,” said Grace Lee, a committee member and a pediatrics professor at Stanford University’s School of Medicine, referring to the industries listed in the two groups of essential workers.

Jose Romero, the panel’s chair and the secretary of the Arkansas health department said the vote was his hardest in the 6½ years he has spent on the committee. “What we are providing governors, health officials with is a framework that is supported by evidence and will address this limited supply of vaccine that we have at this time,” he said.

Henry H. Bernstein, a pediatrics professor at the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell in New York, said he opposed the recommendations because he wanted to see people ages 65 to 74 included in the very next priority group, along with those 75 and older.

President-elect Joe Biden’s covid-19 advisory board supports the phases set forth by the advisory group, said one of its co-chairs, Marcella Nunez-Smith, an associate professor at the Yale School of Medicine. She praised the panel’s experts for “taking political interference out of the process” and said she was “quite excited by their grounding in inequity,” referring to the importance given to factors such as housing and minority status in decisions about prioritization.

But there needs to be greater federal guidance and coordination to prevent a “patchwork that’s appearing in the states” about who gets access and when she said.

Health-care workers share what the coronavirus vaccine means to them
Health-care workers across the U.S. received their first dose of the Pfizer-BioNTech coronavirus vaccine following its Dec. 11 authorization by the FDA. (The Washington Post)

The 14 members of the panel have been wrestling with questions about balancing fairness and speed since spring. They have held nearly a dozen public meetings to examine evidence to address how best to balance saving the lives of the most vulnerable against stopping the spread of the virus and doing so in a way that will lessen health inequities.

They previously recommended that the highest priority be given to health-care workers and residents of long-term care facilities. They signaled at the time that certain essential workers should be prioritized next to address racial disparities exposed by the pandemic and to curb transmission.

Because of the uneven burden of the virus in communities of color, racial equity has been among the reasons immunization experts were looking closely at essential workers, who are disproportionately people of color.

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Unlike the larger population of essential workers, however, the front-line essential workers being given priority in the next phase “more closely model the racial makeup of the total U.S. population,” said Kathleen Dooling, a CDC medical officer.

Katherine A. Poehling, a committee member and pediatrics professor at Wake Forest School of Medicine in North Carolina, called the decisions before the group “wrenching,” saying the aim was to account both for the disproportionate rates of hospitalization and death among the elderly and the higher exposure of workers vital to the functioning of society.

But state officials said the multiple overlapping priority groups threatened to create confusion, even causing local public health agencies to slow down for fear of breaching the guidelines.

Molly Howell of North Dakota, representing the Association of Immunization Managers, said age-based preferences were easiest to enforce, and that the organization’s members were clamoring for additional guidance about the prioritization of essential workers.

Others stressed that efficiency alone should not guide rollout. “We cannot abandon equity because it’s hard to measure and it’s hard to do,” Lee said.

Several members repeated their plea for Congress and federal agencies to provide localities with critical funding needed to implement the most ambitious immunization campaign in U.S. history.

“Today, state and local public health departments are on life support,” said Jeffrey Duchin, a top official for Seattle and King County, Wash., citing the need to train additional immunization staff and conduct outreach to hard-to-reach communities. Referring to the Trump administration initiative to speed vaccine development, he said: “Operation Warp Speed has delivered two Cadillac vaccines to us, but they come with empty gas tanks.”

Helen Keipp K. Talbot, a Vanderbilt University associate professor of medicine, cited barriers to vaccination for front-line workers, such as those who get milk from the farm to the grocery store for her teenage son to drink. The laborers cannot easily take off work to be immunized or stay home if they have side effects.

“This is critical,” said Talbot, a member of the advisory panel. “We need to be working with the White House to fund our state health departments, to get the vaccine out so that everyone can get their milk and eggs.”

With limited supply, states are scrambling to decide which groups get the vaccine next and in what order. States often follow the federal recommendations, but they have the final say in priority groups, which will probably vary widely by state.

If the advisory group recommendation is approved and adopted by CDC Director Robert Redfield, it becomes the official CDC recommendation on immunization. The CDC is also planning to release additional guidance this week to include ways for states to prioritize within groups of essential workers. Workers in areas of high transmission or individuals at increased risk for covid-19 because of age or underlying medical conditions could be offered shots first.

“What the CDC might suggest is the right way may be different than what a given state does because of industry voices, and because what groups might have the ears of governors,” said one public health expert who spoke on the condition of anonymity because he is part of a state vaccine advisory committee.

Companies representing technology, food, aviation, and utility industries are lobbying states and the federal government to prioritize their workers.

The recommendations received wide-ranging criticism in public comments, even as medical experts, health officials, and vaccine advocates hailed the advisory group’s work.

Some said the prioritization of front-line workers would create dilemmas for public health agencies inclined to provide limited resources to those most at risk of the virus. Claire Hannan, executive director of the Association of Immunization Managers, said states and local jurisdictions needed better “communication strategies and talking points,” especially in vaccinating “essential workers who are young and healthy over adults at high risk due to underlying conditions.”

Another gap was the lack of attention to those caring for dependent parents, which several commenters said created unique needs for Asian, Hispanic, and other minority groups. Minh Hoang Tu, a Seattle caregiver attending to her 90-year-old mother with dementia, said the priority groups do not recognize her family’s situation.

“My home functions like a nursing home, but of one resident, and I’m a health-care worker, just unpaid and unlicensed,” she said.