The COVID-19 “Vaccination Line”: An Update on State Prioritization Plans

More recent data on state priorities and phase of vaccine distribution is available.

With COVID-19 vaccine rollout already underway, states are still refining their priority groups, making updates based on new guidance, vaccine supply or distribution issues, and other factors. States first outlined preliminary approaches in October, when they released initial draft plans for vaccine distribution. Then, in early December, they further specified the very first groups to be targeted (Phase 1a), based in large part on initial Centers for Disease Control and Prevention (CDC) guidance, as we described here. But all of that was before the first vaccine was even authorized and any doses shipped. Now, there are two authorized vaccines in the U.S. that began to be delivered to states on December 14. Subsequently, the CDC provided additional guidance on the next groups to be vaccinated (Phases 1b and 1c, see Box).

We sought to gauge where states stand on prioritization and how they may differ from the latest CDC Advisory Committee on Immunization Practices (ACIP) recommendations (summarized below). We also identified where states are in their distribution timelines. It is important to note that state guidelines are fluid, with changes still ongoing. In addition, regardless of group prioritization, states are operating on different timelines so even those in the same priority order in different states may receive their vaccinations at different times. Finally, in many jurisdictions, states have further decentralized decisions about timelines to the local level, which has led to varying timelines of access within the same state.

Overall, we find states are increasingly diverging from CDC guidance and from each other, suggesting that access to COVID-19 vaccines in these first months of the U.S. vaccine campaign may depend a great deal on where one lives. In addition, timelines vary significantly across states, regardless of priority group, resulting in a vaccine roll-out labyrinth across the country.

We reviewed the latest information from all 50 states and the District of Columbia.  As of January 11, 2021, here is how they line up with ACIP recommendations and where they are in their vaccination timelines:

Findings

Priority Groups

• Phase 1a: All states and DC are vaccinating health care workers and long-term care residents and staff in Phase 1a, as recommended by ACIP, though 16 states depart from ACIP in some way, primarily by including other groups:
  • 10 states include additional first responders beyond those working directly in health, such as law enforcement and/or fire personnel (Arkansas, Georgia, Indiana, Maryland, Massachusetts, Nevada, New Hampshire, South Dakota, Virginia, and Wyoming).
  • 1 state (Utah) also includes K-12 and childcare personnel in the first priority group, while another (Louisiana) limits health care workers to hospital staff only (remaining health care workers are included in Phase 1b).
  • 4 states add seniors to their 1a phase priority groups, including people 65 and older in Georgia and Florida, 75 and older in Tennessee, and 80 and older in West Virginia.
  • 5 states include other vulnerable individuals in Phase 1a including 3 (D.C., New Jersey, and Ohio) that include psychiatric patients, 1 (Florida) that includes people deemed to be extremely vulnerable to COVID-19 by hospital providers, and 1 (Tennessee) that includes people who cannot live independently.
  • 2 states include those living in other congregate facilities (beyond long-term care residents) in this phase.  Massachusetts includes people who are incarcerated or homeless and New Jersey includes people who are incarcerated.

• Phase 1b: Most states (44) have updated their Phase 1b priority groups, including 14 that follow ACIP recommendations exactly and 30 that depart in some way, primarily by including additional age groups. States have also prioritized educators and many include those living in congregate settings, such as people who are incarcerated or homeless:
  • 23 states expand the age band in this phase, most commonly for individuals 65 and older (ACIP recommends 75 and older) though one state (Alaska) includes those 55+.
  • A few states also include younger people in this phase who meet certain conditions. For example, Alaska includes people aged 16-54 in “unserved communities”, while Washington state includes people ages 50 to 69 that live in multigenerational households.
  • 18 states either expand (8) or limit (10) the categories of frontline essential workers compared to those recommended by ACIP. For example, Georgia includes all essential workers and Kansas also includes those who are in retail, warehouses, sales, and supplying critical materials for COVID response. Several states limit essential workers to educators (see below) and/or first responders.
  • States have also prioritized K-12 and childcare personnel, one of ACIP’s frontline worker categories for Phase 1b. In addition to the 15 states that follow ACIP’s recommendations and the 8 that expand upon these groups (and therefore include educators), 8 states that define a more limited group of frontline workers in this phase do include educators, sometimes as the only group of frontline workers or sometimes with one or two other groups. Only 3 states (New Jersey, New Hampshire, and Utah) do not include educators in Phase 1b (for Utah, they are included in 1a).
  • 12 states include people with high risk medical conditions in this phase (which ACIP includes in Phase 1c).
  • 2 states (Maryland and Ohio) include people with developmental disabilities in Phase 1b and 1 state (Montana) includes American Indians and other people of color at increased risk for COVID-19 complications.
  • Many states also include residents of other congregate living facilities – primarily corrections and homeless shelters – in Phase 1b (ACIP recommendations state that during Phase 1b, jurisdictions may choose to vaccinate residents of congregate living facilities at the same time as frontline staff due to their shared risk of disease). We found that 18 states do so in this phase.
• Phase 1c: 33 states have updated their Phase 1c priority groups, 17 of which follow ACIP recommendations and 16 which differ. While many of those differences are due to the fact that ACIP-recommended 1c groups were included by many states in earlier phases, there are other differences even after accounting for this, including:
  • 6 states (California, Colorado, Kentucky, Montana, New Hampshire, and New Mexico) expand the age band compared to ACIP.
  • 4 states (Maryland, Montana, New Hampshire, and Tennessee) include a more limited set of essential workers than ACIP (even after accounting for their 1b groups).

Current Phase of Vaccine Distribution

We also assessed where states were in their vaccine distribution timeline, almost one month out from when doses were first shipped. Most states (40) are still in Phase 1a overall, or for a subset of counties within the state. 10 states and DC are in Phase 1b.  Only 1 state (Michigan) has moved to at least part of Phase 1c.

Summary

Even as many states are following CDC ACIP guidance for determining their COVID-19 vaccine priority groups, more are beginning to diverge from federal guidance and from one another. This is especially true as states look to transition beyond Phase 1a and face the challenges of operationalizing broader COVID-19 vaccination. Most of these divergences involve age, with many states moving to include expanded age groups earlier than recommended by ACIP.

In some cases, states are broadening and simplifying the priority groups. But, in other cases, states are creating new and more complex priority groupings. As with many decisions regarding how best to respond to the pandemic, there are trade-offs here. Identifying specific priority groups may more effectively target a limited supply of vaccines, but also lead to greater difficulty in implementing vaccine distribution plans and make it harder to communicate those plans to the public. Because of these differences, for this next period, a person’s place in the COVID-19 vaccine priority line will increasingly depend on where they live.

Table

Table 1: State COVID-19 Vaccine Prioritization and Phase of Vaccine Distribution, as of January 11, 2021