The Advisory Committee on Immunization Practices' Updated Interim

Early Release / Vol. 69 December 22, 2020

Morbidity and Mortality Weekly Report

U.S. Department of Health and Human Services

Centers for Disease Control and Prevention

The Advisory Committee on Immunization Practices’

Updated Interim Recommendation for Allocation of COVID-19 Vaccine —

United States, December 2020

Kathleen Dooling, MD

; Mona Marin, MD

; Megan Wallace, DrPH

1,2

; Nancy McClung, PhD

; Mary Chamberland, MD

1,3

; Grace M. Lee, MD

;

H. Keipp Talbot, MD

; José R. Romero, MD

; Beth P. Bell, MD

; Sara E. Oliver, MD

The first vaccines for prevention of coronavirus disease 2019

(COVID-19) in the United States were authorized for emer-

gency use by the Food and Drug Administration (FDA) (1) and

recommended by the Advisory Committee on Immunization

Practices (ACIP) in December 2020.* However, demand for

COVID-19 vaccines is expected to exceed supply during the

first months of the national COVID-19 vaccination program.

ACIP advises CDC on population groups and circumstances

for vaccine use.

†

On December 1, ACIP recommended that

1) health care personnel

and 2) residents of long-term care

facilities

be offered COVID-19 vaccination first, in Phase 1a

of the vaccination program (2). On December 20, 2020, ACIP

recommended that in Phase 1b, vaccine should be offered

to persons aged ≥75 years and frontline essential workers

(non–health care workers), and that in Phase 1c, persons aged

65–74 years, persons aged 16–64 years with high-risk medi-

cal conditions, and essential workers not recommended for

vaccination in Phase 1b should be offered vaccine.** These

recommendations for phased allocation provide guidance for

federal, state, and local jurisdictions while vaccine supply is

limited. In its deliberations, ACIP considered scientific evi-

dence regarding COVID-19 epidemiology, ethical principles,

and vaccination program implementation considerations.

ACIP’s recommendations for COVID-19 vaccine allocation are

interim and might be updated based on changes in conditions

of FDA Emergency Use Authorization, FDA authorization

* https://www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/covid-19.html.

†

https://www.cdc.gov/vaccines/acip/committee/acip-charter.pdf.

https://www.cdc.gov/infectioncontrol/guidelines/healthcare-personnel/

appendix/terminology.html.

https://www.cdc.gov/longtermcare/index.html.

** On December 20, 2020, ACIP voted 13 to 1 in favor of the Phase 1b and 1c

allocation recommendations.

for new COVID-19 vaccines, changes in vaccine supply, or

changes in COVID-19 epidemiology.

Since June 2020, ACIP has convened 10 public meetings to

review evidence-based information pertaining to COVID-19

vaccines, including initial allocation of COVID-19 vaccine

supplies.

††

To inform policy options for ACIP, the COVID-19

Vaccines Work Group, comprising experts in infectious dis-

eases, vaccinology, vaccine safety, public health, and ethics,

held 28 meetings to review data regarding vaccine candidates,

COVID-19 surveillance, modeling of allocation scenarios, and

vaccination program implementation issues. The Work Group

also considered the relevant scientific literature, including

ethical principles related to vaccine allocation in the setting of

limited supply. Following ACIP’s interim recommendation for

vaccine allocation in Phase 1a (2), the Work Group proposed

vaccine allocation for Phases 1b and 1c. A description of the

population groups in these phases, supporting scientific data,

consideration of ethical principles, and considerations for vac-

cination program implementation are presented in this report,

and supporting evidence is available at https://www.cdc.gov/

vaccines/hcp/acip-recs/vacc-specific/covid-19/evidence-table-

phase-1b-1c.html.

Phase 1b

Approximately 49 million persons, including frontline

essential workers (non–health care workers) and persons aged

≥75 years are recommended to receive vaccine in Phase 1b of

the COVID-19 vaccination program (Table). Essential workers

perform duties across critical infrastructure sectors and main-

tain the services and functions that U.S. residents depend on

††

https://www.cdc.gov/vaccines/acip/meetings/index.html.

Early Release

2 MMWR / December 22, 2020 / Vol. 69

daily. The Cybersecurity and Infrastructure Security Agency

(CISA) of the U.S. Department of Homeland Security has

developed a list intended to guide jurisdictions in identifying

essential critical infrastructure workers, who may be exempted

during stay-at-home-orders (3). ACIP used CISA guidance

to define frontline essential workers as the subset of essential

workers likely at highest risk for work-related exposure to

SARS-CoV-2, the virus that causes COVID-19, because their

work-related duties must be performed on-site and involve

being in close proximity (<6 feet) to the public or to cowork-

ers. ACIP has classified the following non–health care essential

workers as frontline workers: first responders (e.g., firefighters

and police officers), corrections officers, food and agricultural

workers, U.S. Postal Service workers, manufacturing work-

ers, grocery store workers, public transit workers, and those

who work in the education sector (teachers and support staff

members) as well as child care workers.

§§

A tiered approach

for essential workers builds on the occupations identified by

the National Academies of Science, Engineering and Medicine

for early vaccination (4).

Although there is no national surveillance for COVID-19

among frontline or other essential workers, reports of high inci-

dence and outbreaks within multiple critical infrastructure sec-

tors illustrate the COVID-19 risk in these populations and the

disproportionate impact of COVID-19 on workers who belong

to racial and ethnic minority groups. During March–June,

for example, the Utah Department of Heath reported 1,389

COVID-19 cases associated with workplace outbreaks in 15

industry sectors, accounting for 12% of all COVID-19 cases in

Utah during the same period (5). In addition, despite represent-

ing 24% of Utah workers in all affected sectors, Hispanic and

non-White workers accounted for 73% of COVID-19 cases in

workplace-associated outbreaks (5). Among 23 states reporting

COVID-19 outbreaks in meat and poultry processing facilities

during April and May, 16,233 outbreak-associated cases were

reported from 239 facilities, including 86 COVID-19–related

deaths (6). The percentage of workers with COVID-19 ranged

from 3% to 25% per facility, and among cases with information

on race and ethnicity reported, 87% occurred among workers

from racial or ethnic minority groups (6).

Persons aged ≥75 years are at high risk for COVID-19–associated

morbidity and mortality. As of December 20, 2020, the

cumulative incidence

¶¶

of COVID-19 among persons in this

age group was 3,839 per 100,000 persons, with a cumulative

hospitalization rate of 1,211 per 100,000, and a mortality rate

of 719 per 100,000 (7–9). The overall proportion of persons

aged ≥75 years who live in a multigenerational household is

6%; the proportion among non-Hispanic White persons is 4%,

and the proportion among racial or ethnic minority groups is

higher (non-Hispanic Black persons, 10%; Hispanic or Latino

persons, 18%; non-Hispanic persons of other races, 20%).***

§§

https://www.cdc.gov/vaccines/covid-19/categories-essential-workers.html.

¶¶

Incidences were calculated using age-specific population denominators from

the U.S. Census. https://www.census.gov/data.html.

*** Data from the U.S. Census Bureau 2019 American Community Survey 1-Year

Public Use Microdata Samples [CSV file]. https://www2.census.gov/programs-

surveys/acs/data/pums/2019/1-Year/. Accessed December 16, 2020.

TABLE. Advisory Committee on Immunization Practices recommendations for allocation of COVID-19 vaccines to persons aged ≥16 years —

United States, December 2020

Phase

Groups recommended

to receive COVID-19 vaccine

No. (millions)

Total persons

in each group*

Unique persons

in each group

†

Unique persons

in each phase

1a Health care personnel 21 21 24

Long-term care facility residents 3 3

1b Frontline essential workers

30 30 49

Persons aged ≥75 years 21 19

1c Persons aged 65–74 years 32 28 129

Persons aged 16–64 years

with high-risk

medical conditions

110 81

Essential workers

not recommended for

vaccination in Phase 1b

57 20

2 All persons aged ≥16 years

not previously

recommended for vaccination

All remaining All remaining All remaining

Abbreviation: COVID-19 = coronavirus disease 2019.

* Data sources for each group: health care personnel (American Community Survey, 2019; https://www.census.gov/programs-surveys/acs/data.html); long-term care

facility residents (Minimum Data Set. Centers for Medicare & Medicaid Services; https://data.cms.gov/); frontline and other essential workers (American Community

Survey, 2019; https://www.census.gov/programs-surveys/acs/data.html); age-specific groups (U.S. Census; https://data.census.gov/cedsci/); high-risk medical

conditions (Behavioral Risk Factors Surveillance System, 2018; https://www.cdc.gov/brfss/annual_data/annual_data.htm).

†

Excludes persons who were recommended to receive vaccine in an earlier phase (e.g., persons aged 65–74 years who are living in long-term care facilities or who

are health care personnel, who would have been included in Phase 1a) and accounting for overlap between groups within the same phase (e.g., essential workers

with high risk medical conditions).

Estimates for frontline and other essential workers are approximate and derived from prepandemic survey data; relative proportions will vary by state.

As of December 18, only the Pfizer-BioNTech COVID-19 vaccine is authorized for use in persons aged 16–17 years.

Early Release

MMWR / December 22, 2020 / Vol. 69 3

Phase 1c

In Phase 1c, vaccine should be offered to persons aged

65–74 years, persons aged 16–64 years

†††

with medical

conditions that increase the risk for severe COVID-19, and

essential workers not previously included in Phase 1a or 1b.

Approximately 129 million persons are included in Phase 1c

(Table), accounting for the overlap between groups in Phase 1c

and earlier phases; for example, some adults aged 65–74 years

reside in long-term care facilities, and many essential workers

have high-risk medical conditions. Persons aged 65–74 years

are at high risk for COVID-19–associated morbidity and mor-

tality. As of December 20, 2020, the cumulative COVID-19

incidence in this age group was 3,109 per 100,000 persons,

with a cumulative hospitalization rate of 642 per 100,000, and

a mortality rate of 188 per 100,000 (7–9).

Based on ongoing review of the literature, CDC has identi-

fied medical conditions or risk behaviors that are associated

with increased risk for severe COVID-19.

§§§

The risk for

COVID-19–associated hospitalization increases with the num-

ber of high-risk medical conditions, from 2.5 times the risk for

hospitalization for persons with one condition to 5 times the

risk for those with three or more conditions (10). According to

a recent analysis of 2018 Behavioral Risk Factor Surveillance

System data,

¶¶¶

at least 56% of persons aged 18–64 years report

at least one high-risk medical condition (CDC COVID-19

Response Team, Division of Population Health, personal

communication, December 2020). Essential worker sectors

recommended for vaccination in Phase 1c include those in

transportation and logistics, water and wastewater, food ser-

vice, shelter and housing (e.g., construction), finance (e.g.,

bank tellers), information technology and communications,

†††

As of December 18, 2020, two COVID-19 vaccines have been authorized

for use under an Emergency Use Authorization (EUA), but only the

Pfizer-BioNTech COVID-19 vaccine is authorized for use in persons aged

16–17 years.

§§§

Adults of any age with the following conditions are at increased risk for

severe COVID-19–associated illness: cancer; chronic kidney disease; chronic

obstructive pulmonary disease (COPD); heart conditions, such as heart

failure, coronary artery disease, or cardiomyopathies; immunocompromised

state (weakened immune system) from solid organ transplant; obesity

(body mass index [BMI] ≥30 kg/m

but <40 kg/m

); severe obesity

(BMI ≥40 kg/m

); sickle cell disease; smoking; type 2 diabetes mellitus;

and pregnancy. No data are currently available on the safety of COVID-19

vaccines in pregnant persons. If pregnant persons are part of a group that

is recommended to receive a COVID-19 vaccine (e.g., health care personnel

or essential worker), they may choose to be vaccinated. A conversation

between the patient and the patient’s clinical team might assist with

decisions regarding the use of vaccines approved under EUA for the

prevention of COVID-19. Guidance for pregnant persons will be updated

as new data becomes available at https://www.cdc.gov/vaccines/covid-19/

info-by-product/clinical-considerations.html. The list of high-risk medical

conditions is updated routinely as new data becomes available at https://

www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/people-with-

medical-conditions.html.

¶¶¶

https://www.cdc.gov/brfss/annual_data/annual_data.htm.

energy, legal, media, public safety (e.g., engineers), and public

health workers.****

ACIP’s ethical principles for allocating initial supplies

of COVID-19 vaccine, namely, to maximize benefits and

minimize harms, promote justice, and mitigate health ineq-

uities (11), support the allocation scheme for Phases 1b and

1c. Allocation of COVID-19 vaccine to essential workers

and persons at increased risk for severe COVID-19 disease

balances the vaccination program priorities of minimizing

societal disruption and preventing morbidity and mortality.

Essential workers constitute a large and heterogenous group.

Allocation of vaccine to frontline essential workers in Phase 1b

acknowledges their increased risk for occupational exposure

compared with other essential worker categories, as well as the

benefits to society of maintaining these essential functions.

Allocation to persons aged ≥75 years is supported by their

high risk for COVID-19–associated morbidity and mortality

and is anticipated to also reduce hospitalizations in this group,

easing the burden on strained health care systems. Populations

included in Phase 1c are either at an increased risk for severe

COVID-19 compared with the general population or support

ongoing critical infrastructure operations. In addition, certain

essential worker groups have high proportions of some racial

and ethnic minority groups who have experienced dispropor-

tionate COVID-19 incidence, morbidity, and mortality (12).

Implementing vaccination programs to reach essential work-

ers will pose challenges. Use of multiple strategies is recom-

mended to reduce barriers to vaccination,

††††

such as providing

**** Certain occupations in Phase 1b might be related to sectors listed in Phase 1c

(public transit [transportation and logistics], grocery store workers [food

services], and corrections workers [public safety]).

††††

COVID-19 Vaccination Communication Toolkit. https://www.cdc.gov/

vaccines/covid-19/health-systems-communication-toolkit.html.

Summary

What is already known about this topic?

On December 1, the Advisory Committee on Immunization

Practices (ACIP) recommended that health care personnel and

long-term care facility residents be offered COVID-19

vaccination first (Phase 1a).

What is added by this report?

On December 20, ACIP updated interim vaccine allocation

recommendations. In Phase 1b, COVID-19 vaccine should be

offered to persons aged ≥75 years and non–health care

frontline essential workers, and in Phase 1c, to persons aged

65–74 years, persons aged 16–64 years with high-risk medical

conditions, and essential workers not included in Phase 1b.

What are the implications for public health practice?

Federal, state, and local jurisdictions should use this guidance

for COVID-19 vaccination program planning and implementation.

Early Release

4 MMWR / December 22, 2020 / Vol. 69

vaccination opportunities at or close to the workplace. State

and local health authorities will need to take local COVID-19

epidemiology and demand for vaccine into account when

deciding to proceed to the next phase or to subprioritize

within an allocation phase if necessary. A flexible approach to

allocation will facilitate efficient management and ensure that

COVID-19 vaccine is administered equitably and without

delay. Additional interim considerations for phased implemen-

tation of COVID-19 vaccines are available at https://www.cdc.

gov/vaccines/covid-19/initial-populations.html and https://

www.cdc.gov/vaccines/covid-19/phased-implementation.html.

Phase 2

Phase 2 includes all other persons aged ≥16 years not

already recommended for vaccination in Phases 1a, 1b, or 1c.

Currently, in accordance with recommended age and condi-

tions of use (1), any authorized COVID-19 vaccine may be

used. ACIP is closely monitoring clinical trials in children

and adolescents and will consider recommendations for use

when a COVID-19 vaccine is authorized for use in persons

aged <16 years.

Acknowledgments

Voting members of the Advisory Committee on Immunization

Practices: Robert L. Atmar, Baylor College of Medicine; Kevin A.

Ault, University of Kansas Medical Center; Lynn Bahta, Minnesota

Department of Health; Henry Bernstein, Zucker School of Medicine

at Hofstra/Northwell Cohen Children’s Medical Center; Sharon E.

Frey, Saint Louis University Medical School; Paul Hunter, City of

Milwaukee Health Department; Veronica V. McNally, Franny Strong

Foundation; Katherine A. Poehling, Wake Forest School of Medicine;

Pablo J. Sanchez, The Research Institute at Nationwide Children’s

Hospital; Peter Szilagyi, University of California, Los Angeles.

Members of the Advisory Committee on Immunization Practices

COVID-19 Vaccines Work Group: Edward Belongia, Center for

Clinical Epidemiology & Population Health, Marshfield Clinic

Research Institute; Dayna Bowen Matthew, George Washington

University Law School; Oliver Brooks, National Medical Association;

Matthew Daley, Institute for Health Research, Kaiser Permanente

Colorado; Jillian Doss-Walker, Indian Health Service; Marci Drees,

Society for Healthcare Epidemiology of America; Jeffrey Duchin,

Infectious Diseases Society of America; Doran Fink, Food and Drug

Administration; Sandra Fryhofer, American Medical Association;

Jason M. Goldman, American College of Physicians; Michael Hogue,

American Pharmacists Association; Denise Jamieson, American

College of Obstetricians and Gynecologists; Jeffery Kelman,

Centers for Medicare & Medicaid; David Kim, U.S. Department

of Health and Human Services; Kathy Kinlaw, Center for Ethics,

Emory University; Susan Lett, Council of State and Territorial

Epidemiologists; Kendra McMillan, American Nurses Association;

Kathleen Neuzil, Center for Vaccine Development and Global

Health, University of Maryland School of Medicine; Sean O’Leary,

American Academy of Pediatrics; Christine Oshansky, Biomedical

Advanced Research and Development Authority; Stanley Perlman,

Department of Microbiology and Immunology, University of Iowa;

Marcus Plescia, Association of State and Territorial Health Officials;

Chris Roberts, National Institutes of Health; William Schaffner,

National Foundation for Infectious Diseases; Rob Schechter,

Association of Immunization Managers; Kenneth Schmader,

American Geriatrics Society; Bryan Schumacher, Department of

Defense; Jonathan Temte, American Academy of Family Physicians;

Matthew Tunis, National Advisory Committee on Immunization

Secretariat, Public Health Agency of Canada; Thomas Weiser, Indian

Health Service; Matt Zahn, National Association of County and City

Health Officials; Rachel Zhang, Food and Drug Administration.

Corresponding author: Kathleen Dooling, [email protected]v.

CDC COVID-19 Response Team;

Epidemic Intelligence Service, CDC;

General Dynamics Information Technology, Falls Church, Virginia;

Stanford

University School of Medicine, Stanford, California;

Vanderbilt University

School of Medicine, Nashville, Tennessee;

Arkansas Department of Health;

University of Washington, Seattle, Washington.

All authors have completed and submitted the International

Committee of Medical Journal Editors form for disclosure of potential

conflicts of interest. No potential conflicts of interest were disclosed.

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