The Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices recommended on Sunday that frontline essential workers and people 75 and older should be next in line for coronavirus vaccines.
Healthcare workers and residents of long-term care facilities have already started receiving their shots.
The US should have enough shots to complete these first two phases of vaccinations sometime in February.
The third round of shots should go to people ages 65 to 74, people ages 16 to 64 with high-risk medical conditions, and any other essential workers who haven't been vaccinated yet, the CDC recommended.
People 75 and older and frontline essential workers should be next in line to receive coronavirus vaccines, the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices recommended at a Sunday meeting.
This second priority group constitutes about 49 million people, according to the CDC. The US is already vaccinating its first priority group: roughly 21 million healthcare workers and 3 million residents of long-term care facilities.
The CDC's recommendations are based on two key goals: preventing disease transmission and mortality, and preserving the overall function of society.
Protecting older people from COVID-19 is critical to that first goal. People 75 and older represent one-quarter of COVID-19 hospitalizations and about 60% of COVID-19 deaths in the US, according to the CDC.
Frontline essential workers, meanwhile, are necessary for a functioning society and face an increased risk of exposure to the coronavirus because of the public-facing nature of their work.
Data from the coronavirus outbreak in New York City from May to July suggested that an overwhelming number of workers in public service agencies got infected: On average, 22% of their antibody tests came back positive. Among these workers, correctional staffers had the highest positivity rate, at nearly 40%.
The CDC classified frontline essential workers as first responders (firefighters and police officers) and workers in education (teachers, school support staffers, and daycare workers), food and agriculture, manufacturing, corrections, the US Postal Service, public transit, and grocery stores.
The advisory committee said that once these people are vaccinated, the third round of shots should go to people ages 65 to 74, people ages 16 to 64 with high-risk medical conditions, and any other essential workers who haven't been vaccinated yet.
These remaining essential workers would include those in transportation, food service, construction, finance, information technology and communication, energy, media, law, engineering, and water and waste management.
High-risk medical conditions, according to the CDC, include obesity or severe obesity, Type 2 diabetes, chronic obstructive pulmonary disease, heart conditions, chronic kidney disease, cancer, an immunocompromised state from a solid organ transplant, sickle-cell disease, pregnancy, or a history or current practice of smoking.
In total, this third phase would include roughly 129 million people.
But ultimately it's up to each state to decide how to prioritize its vulnerable populations.
"There will be difficult choices about who gets that vaccine first," Dr. Nancy Messonnier, the director of the National Center for Immunization and Respiratory Diseases at the CDC, said at Sunday's meeting.
If doses are scarce, the advisory committee said, states might consider prioritizing vaccinations for frontline essential workers in areas with high transmission, who haven't had COVID-19 in the past 90 days, or who have an increased risk of severe illness based on their age or underlying medical problems.
States might also consider vaccinating residents of congregate-living facilities - such as prisons, jails, and homeless shelters - at the same time as the facilities' staff members, the committee said.
Vaccinating 2 priority groups by February
The Food and Drug Administration has authorized two shots for emergency use in the US. Moderna's vaccine was authorized on Friday and could be administered as early as Monday. Pfizer's vaccine was authorized on December 11 and is already being given out across the country.
Healthcare workers were the first to receive their shots last Monday. CVS and Walgreens started giving shots to residents of long-term care facilities on Friday.
A recent Kaiser Family Foundation report found that 45 states were following the CDC advisory group's recommendations, but a few were veering slightly off course. Nevada, New Hampshire, and Wyoming, for instance, were including law-enforcement officials in their first round of vaccinations, while Massachusetts was including incarcerated people and people in homeless shelters.
Over the past week, about 2.8 million doses have been distributed and more than 556,000 doses have been administered in the US, according to the CDC.
Federal officials have estimated that 100 million people could get their full two-dose regimen before March. (Pfizer's vaccine is given as two doses taken 21 days apart, while Moderna's is given as two doses taken 28 days apart.)
"There should be enough vaccine to vaccinate 20 million people in December, 30 million people in January, and 50 million people in February," Messonnier said Sunday.
That means the US should have enough shots to complete its first two rounds of vaccinations (phases 1a and 1b in the chart below) in February. The third round of vaccinations (phase 1c) could also begin that month.
Other people might start getting immunized by April, according to the CDC's timeline. By that point, the country could be vaccinating 10 million people per week.
Moncef Slaoui, who is spearheading the US's Operation Warp Speed vaccine effort, told The Washington Post that most Americans could be immunized by the middle of 2021.
But that timeline is optimistic, other experts say. Dr. Vivek Murthy, President-elect Joe Biden's nominee for US surgeon general, estimated on Sunday that people might not receive their shots until midsummer or early fall.
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