TABLE 2. Application of ethical principles to four candidate groups for initial COVID-19 vaccine allocation — United States, 2020.

Principles (with transparency across the decision-making process)	Candidate groups* (approximate no.)
	Health care personnel† (21 million)	Other essential workers† (87 million)	Adults with high-risk medical conditions§ (>100 million)	Adults aged ≥65 years (53 million)
Maximize benefits and minimize harms	Preserves health care services essential to the COVID-19 response and the overall health care system	Preserves services essential to the COVID-19 response and overall functioning of society	Reduces morbidity and mortality in persons with high incidence of COVID-19 disease and death**	Reduces morbidity and mortality in persons with high incidence of COVID-19 disease and death††
	Multiplier effect¶	Multiplier effect¶
Promote justice	Addresses elevated occupational risk for SARS-CoV-2 exposure for those unable to work from home	Addresses elevated occupational risk for SARS-CoV-2 exposure for those unable to work from home	Will require focused outreach to vaccinate persons in this group who have no or limited access to health care or experience inequities in social determinants of health	Will require focused outreach to vaccinate persons in this group who have no or limited access to health care or experience inequities in social determinants of health
	Promotes access to vaccine across a spectrum of HCP job types and settings	Promotes access to vaccine and reduces barriers to vaccination in occupations with low vaccine uptake§§
Mitigate health inequities	Racial and ethnic minority groups are disproportionately represented in low-wage HCP¶¶	Racial and ethnic minority groups are disproportionately represented in many essential industries***	Increased prevalence of obesity and diabetes (most prevalent conditions in this group) among some racial and ethnic minority groups; increased prevalence of some medical conditions for persons in rural areas§§§	Although racial and ethnic minority groups are underrepresented among adults aged ≥65 years, certain groups have disproportionate COVID-19–related hospitalization and death rates¶¶¶
		Approximately one quarter of essential workers live in low-income families†††	Could increase health inequities because diagnosis of high-risk medical conditions requires access to health care	Strict age-based criterion could increase disparities due to racial and social inequities, such as occupation, income, access to health care

Abbreviations: COVID-19 = coronavirus disease 2019; HCP = health care personnel.

* Health care personnel: paid and unpaid persons serving in health care settings who have the potential for direct or indirect exposure to patients or infectious materials; other essential workers: person who conduct operations vital for continuing critical infrastructure, such as food, agriculture, transportation, education, and law enforcement; adults with high risk medical conditions: adults who have one or more high-risk medical conditions, such as obesity, diabetes, and cardiovascular disease; adults aged ≥65 years: includes adults living at home and approximately 3 million living in long-term care facilities. There is considerable overlap between groups, for example, many adults aged ≥65 years also have high-risk medical conditions.

^† Essential workers during the COVID-19 response have been defined by the U.S. Department of Homeland Security Cybersecurity and Infrastructure Security Agency. https://www.cisa.gov/sites/default/files/publications/Version_4.0_CISA_Guidance_on_Essential_Critical_Infrastructure_Workers_FINAL%20AUG%2018v2_0.pdf.

^§ Medical conditions considered high-risk are updated routinely based on the best available scientific data: https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/people-with-medical-conditions.html.

^¶ The ability of one or more groups to remain healthy helps protect the health of others and/or minimize disruption to society and the economy.

** As of October 31, 2020, nearly 90% of persons with COVID-19–associated hospitalizations have at least one high-risk condition. Data are routinely updated through COVID-19–Associated Hospitalization Surveillance Network (COVID-NET) (https://gis.cdc.gov/grasp/COVIDNet/COVID19_5.html); in-hospital deaths reported to COVID-NET during March–May, 2020 were associated with certain underlying medical conditions (https://academic.oup.com/cid/advance-article/doi/10.1093/cid/ciaa1012/5872581).

^†† As of November 12, 2020, 80% of COVID-19 deaths were among adults aged ≥65 years. Data are routinely updated through CDC case-based surveillance (https://covid.cdc.gov/covid-data-tracker/#demographics); long-term care residents account for a large proportion of deaths among adults aged ≥65 years (https://data.cms.gov/stories/s/COVID-19-Nursing-Home-Data/bkwz-xpvg/).

^§§ Influenza vaccination coverage is low among many non–health care essential workers; such coverage is lowest among construction workers (10.7%) (https://www.cdc.gov/niosh/docs/2012-161/pdfs/2012-161.pdf?id = 10.26616/NIOSHPUB2012161).

^¶¶ Health Resources and Services Administration estimates from American Community Survey 2011–2015 (https://bhw.hrsa.gov/sites/default/files/bhw/nchwa/diversityushealthoccupationstechnical.pdf).

*** Among 742 food and agriculture workplaces in 30 states, 73% of workers were Hispanic or Latino and 83% of COVID-19 cases occurred in racial or ethnic minority workers (https://wwwnc.cdc.gov/eid/article/27/1/20-3821_article).

^††† Center for Economic and Policy Research estimates from American Community Survey, 2014–2018 (https://cepr.net/a-basic-demographic-profile-of-workers-in-frontline-industries).

^§§§ National Center for Health Statistics. National Health Interview Survey, 2018. Estimates not available for Hawaiian/other Pacific Islander persons or for chronic kidney disease among American Indian/Alaska Native persons (https://www.cdc.gov/nchs/nhis/ADULTS/www/index.htm; https://www.cdc.gov/mmwr/volumes/69/wr/mm6929a1.htm).

^¶¶¶ As of October 31, 2020, compared with COVID-19 hospitalization rates for adults aged ≥65 years who are non-Hispanic White, such rates were higher among adults aged ≥65 years who were non-Hispanic Black (rate ratio [RR] = 3.3), Hispanic or Latino (RR = 2.6), and non-Hispanic American Indian or Alaska Native (RR = 2.4). Data are routinely updated through COVID-NET (https://www.cdc.gov/coronavirus/2019-ncov/covid-data/covidview/index.html); adults aged ≥65 years who are Hispanic or non-Hispanic Black experience disproportionate COVID-19–associated death rates (https://www.cdc.gov/nchs/nvss/vsrr/covid19/health_disparities.htm).