On December 1, 2020, the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention’s (CDC), issued an initial recommendation, adopted by the CDC director, that health care personnel and residents of long-term care facilities should be the first to be offered a COVID-19 vaccine once it is authorized or approved by the FDA (See Appendix A). The ACIP recommendation recognizes that health care workers, who are at higher risk of exposure to people with COVID-19, are essential for preserving health care capacity during the pandemic. Further, it recognizes that long-term care residents are at high risk of serious illness if infected with the virus and account for 40% of all COVID-19 deaths. States have the authority to make their own allocation decisions, although most will likely follow the ACIP guidelines for the initial priority groups.

This analysis provides new national and state-level estimates of the number of health care workers and long-term care residents who are expected to be part of the group first in line to receive the COVID-19 vaccine to gain insight into how this initial priority population varies across states. These estimates are based on our analysis of the 2019 American Community Survey (ACS) and Certification and Survey Provider Enhanced Reports (CASPER) data.

Our health care worker estimates may be lower than others because they are limited to people working in health care settings who are likely to have direct patient contact based on their occupation and who have current ties to the workforce. We include workers providing direct clinical care, such as doctors, nurses, and aides; workers providing direct patient support, such as environmental and food staff; and first-line supervisors and managers of these occupations. Moreover, the estimates are based on state of residence of the health care worker. Some health care workers may work in a different jurisdiction than where they live. For example, many health care workers in the District of Columbia live in Virginia and Maryland. Our national estimates of long-term care facility residents include individuals living in certified nursing facilities and assisted living facilities, but not others who live in other residential settings. Due to data limitations, our state-level estimates do not include people who live in assisted living facilities or in other residential settings.

Findings

Nationwide, there are 19.7 million adults working in health care settings, of which roughly 15.5 million are estimated to have direct patient contact. In addition, there are 1.2 million nursing facility residents and about 800,000 assisted living facility residents. Together, health care workers with direct patient contact and residents in either nursing facility or assisted living facilities account for approximately 17.6 million people or about 7% of the adult population in the U.S.

The number of people in this initial priority group varies widely across states. The number of adults who are health care workers who have direct patient contact or are nursing facility residents ranges from 23,800 who live in Washington, D.C. to nearly 1.7 million who live in California, while the share of adults in these groups varies from roughly 4.4% in DC to at least 8% in 7 states, with North Dakota having the highest share (10%), following by Pennsylvania (8.3%), Minnesota (8.1%) and Rhode Island (8.1%). As noted earlier these estimates do not include people who live in assisted living facilities or in other residential settings.

Discussion

The Department of Health and Human Services (HHS) has announced that about 40 million doses of vaccine could be available by the end of December 2020, enough to vaccinate 20 million people given that two doses are required for the main vaccine regiments that are furthest along in the authorization process. More recent media reports indicate the number of vaccines available for early distribution may be lower than initially projected. HHS plans to allocate vaccinations to states based on each state’s share of the total U.S. adult population but, to date, has not publicly released information on the actual number of vaccines that will be allocated to each state.

Variations in the number of health care workers and long-term care residents across states may result in uneven effects across states in their ability to immunize priority populations using their initial vaccine allotments. While some states may have an adequate supply to vaccinate their priority population, others may fall short and may need to decide who goes first among people in this initial group. Further, as states allocate vaccines down to the local level, the ability of counties, municipalities, and health care systems to vaccinate health care workers and long-term care residents could vary, depending on their supply of vaccines and the demographics of their communities. In instances where supply is insufficient to fully vaccinate the initial priority population, ACIP notes that jurisdictions may consider first offering the vaccine to health care personnel whose duties require proximity (within 6 feet) to other people and that, if vaccine supply remains limited, additional factors might be considered for sub-prioritization of health care personnel. Similarly, ACIP notes that jurisdictions might consider first offering vaccinations to residents and health care personnel in skilled nursing facilities because of the risk of COVID-19 related mortality among residents in those settings.

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