Frontline essential workers and people 75 years of age and older in the United States should get COVID-19 vaccines in the next wave of immunizations, an independent committee at the Centers for Disease Control and Prevention recommended. That group includes about 49 million people.

After those groups are vaccinated, the Advisory Committee on Immunization Practices (ACIP) said doses should go to people between 65 and 74 years old, people between 16 and 65 years old with underlying health conditions, and other essential workers not in groups considered frontline.

Vaccines will be in limited supply through at least the next few months. The CDC expects that there should be doses available to vaccinate 20 million people in December, 30 million people in January, and 50 million people in February. “In this setting, difficult choices have to be made,” Kathleen Dooling, medical officer at the CDC, said in a presentation to the ACIP.

States and local jurisdictions ultimately make the final decisions around the distribution and prioritization of vaccinations, but the CDC recommendations help shape their approaches.

The first phase of vaccinations are going to health care workers and long term care facility residents. Those groups started to get vaccinated last week, and over 200,000 people in the US have been vaccinated so far.

The ACIP balanced two main goals to make recommendations for the second wave of vaccinations: preventing death and disease and preserving societal function. Older adults over 75 have the highest risk of hospitalization and death from COVID-19. Frontline essential workers — which the committee says includes firefighters, teachers, grocery store workers, manufacturing workers, and others — are unable to work from home and often have to interact with the public, putting them at risk of exposure to the virus. Keeping those groups healthy will help keep key services running.

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“This approach mitigates health inequities as racial and ethnic minorities are disproportionately represented in many essential industries,” Dooling said.

The third group the committee says should be vaccinated includes essential workers like people working in food service, construction, transportation, wastewater, and media. People between 65 and 74 are also at high risk of hospitalization and death from COVID-19, as are younger people with underlying health conditions like cardiac disease or diabetes.

While the CDC has a list of workplaces that it considers frontline and essential, different states will set those designations in different ways. Various interest groups are lobbying states to include their workers in early vaccination groups — Uber, for example, asked states to prioritize its drivers.

Distributing vaccines to the second and third wave of priority groups will be difficult. It’s hard to determine eligibility, for example, and reaching essential workers (who may not be able to take time off of work, or may live in rural areas) is a challenge. Committee members stressed the importance of adequate funding for vaccine distribution. Money was funneled into vaccine development, which led to the overwhelmingly effective final products. Local health departments need the same level of investment in vaccination programs. The vaccines are Cadillacs, Jeffrey Duchin, a health officer in King County, Washington, said during the meeting. “But they’ve come with empty gas tanks,” he said.

Over 200,000 people are being diagnosed with COVID-19 in the US each day. Over 2,500 people in the US are dying from the disease every day.

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