The Advisory Committee on Immunization Practices’ Updated Interim Recommendation for Allocation of COVID-19 Vaccine — United States, December 2020

The emergence of SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19), has led to a global pandemic that has disrupted all sectors of society. Less than 1 year after the SARS-CoV-2 genome was first sequenced, an application* for Emergency Use Authorization for a candidate vaccine has been filed with the Food and Drug Administration (FDA). However, even if one or more vaccine candidates receive authorization for emergency use, demand for COVID-19 vaccine is expected to exceed supply during the first months of the national vaccination program. The Advisory Committee on Immunization Practices (ACIP) advises CDC on population groups and circumstances for vaccine use. † ACIP convened on December 1, 2020, in advance of the completion of FDA’s review of the Emergency Use Authorization application, to provide interim guidance to federal, state, and local jurisdictions on allocation of initial doses of COVID-19 vaccine. ACIP recommended that, when a COVID-19 vaccine is authorized by FDA and recommended by ACIP, both 1) health care personnel § and 2) residents of long-term care facilities (LTCFs) ¶ be offered vaccination in the initial phase of the COVID-19 vaccination program (Phase 1a**). †† In its deliberations, ACIP considered scientific evidence of SARS-CoV-2 epidemiology, vaccination program implementation, and ethical principles. §§ The interim recommendation might be updated over the coming weeks based on additional safety and efficacy data from phase III clinical trials and conditions of FDA Emergency Use Authorization. Evidence-based information addressing COVID-19 vaccine topics including early allocation has been explicitly and transparently reviewed during seven public ACIP meetings ( 1 ). To inform policy options for ACIP, the COVID-19 Vaccines Work Group, comprising experts in vaccines and ethics, held more than 25 meetings to review data regarding vaccine candidates, COVID-19 surveillance, and modeling, as well as the vaccine allocation literature from published and external expert committee reports. Health care settings in general, and long-term care settings in particular, can be high-risk locations for SARS-CoV-2 exposure and transmission ( 2 – 4 ). Health care personnel are defined as paid and unpaid persons serving in health care settings who have the potential for direct or indirect exposure to patients or infectious materials. As of December 1, 2020, approximately 245,000 COVID-19 cases and 858 COVID-19-associated deaths had been reported among U.S. health care personnel ( 5 ). Early protection of health care personnel is critical to preserve capacity to care for patients with COVID-19 or other illnesses. LTCF residents are defined as adults who reside in facilities that provide a range of services, including medical and personal care, to persons who are unable to live independently. LTCF residents, because of their age, high rates of underlying medical conditions, and congregate living situation, are at high risk for infection and severe illness from COVID-19. As of November 15, 2020, approximately 500,000 COVID-19 cases and 70,000 associated deaths had been reported among residents of skilled nursing facilities, a subset of LTCFs serving residents with more complex medical needs ( 6 ). With respect to vaccination program implementation, vaccines that require cold and ultracold storage, specialized handling, and large minimum order requirements are most feasibly maintained in centralized vaccination clinics, such as acute health care settings, or through the federal Pharmacy Partnership for Long-term Care Program. ¶¶ ACIP’s ethical principles for allocating initial supplies of COVID-19 vaccine, namely to maximize benefits and minimize harms, promote justice, and mitigate health inequities ( 7 ), support the early vaccination of health care personnel and LTCF residents. Approximately 21 million U.S. health care personnel work in settings such as hospitals, LTCFs, outpatient clinics, home health care, public health clinical services, emergency medical services, and pharmacies. Health care personnel comprise clinical staff members, including nursing or medical assistants and support staff members (e.g., those who work in food, environmental, and administrative services) ( 8 ). Jurisdictions might consider first offering vaccine to health care personnel whose duties require proximity (within 6 feet) to other persons. If vaccine supply remains constrained, additional factors might be considered for subprioritization.*** Public health authorities and health care systems should work together to ensure COVID-19 vaccine access to health care personnel who are not affiliated with hospitals. Approximately 3 million adults reside in LTCFs, which include skilled nursing facilities, nursing homes, and assisted living facilities. Depending upon the number of initial vaccine doses available, jurisdictions might consider first offering vaccination to residents and health care personnel in skilled nursing facilities because of high medical acuity and COVID-19–associated mortality ( 6 ) among residents in these settings. Monitoring vaccine safety in all populations receiving COVID-19 vaccine is required under an Emergency Use Authorization. Vaccines are being studied in older adults with underlying health conditions; however, LTCF residents have not been specifically studied. ACIP members called for additional active safety monitoring in LTCFs to ensure timely reporting and evaluation of adverse events after immunization. ACIP will consider vaccine-specific recommendations and additional populations for vaccine allocation beyond Phase 1a when an FDA-authorized vaccine is available. Summary What is already known about this topic? Demand is expected to exceed supply during the first months of the national COVID-19 vaccination program. What is added by this report? The Advisory Committee on Immunization Practices (ACIP) recommended, as interim guidance, that both 1) health care personnel and 2) residents of long-term care facilities be offered COVID-19 vaccine in the initial phase of the vaccination program. 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. ACIP will consider vaccine-specific recommendations and additional populations when a Food and Drug Administration–authorized vaccine is available.

Abstract Background Data on risk factors for COVID-19-associated hospitalization are needed to guide prevention efforts and clinical care. We sought to identify factors independently associated with COVID-19-associated hospitalizations Methods U.S. community-dwelling adults (≥18 years) hospitalized with laboratory-confirmed COVID-19 during March 1–June 23, 2020 were identified from the COVID-19-Associated Hospitalization Surveillance Network (COVID-NET), a multi-state surveillance system. To calculate hospitalization rates by age, sex, and race/ethnicity strata, COVID-NET data served as the numerator and Behavioral Risk Factor Surveillance System estimates served as the population denominator for characteristics of interest. Underlying medical conditions examined included hypertension, coronary artery disease, history of stroke, diabetes, obesity [BMI ≥30 kg/m 2], severe obesity [BMI≥40 kg/m 2], chronic kidney disease, asthma, and chronic obstructive pulmonary disease. Generalized Poisson regression models were used to calculate adjusted rate ratios (aRR) for hospitalization Results Among 5,416 adults, hospitalization rates were higher among those with ≥3 underlying conditions (versus without)(aRR: 5.0; 95%CI: 3.9, 6.3), severe obesity (aRR:4.4; 95%CI: 3.4, 5.7), chronic kidney disease (aRR:4.0; 95%CI: 3.0, 5.2), diabetes (aRR:3.2; 95%CI: 2.5, 4.1), obesity (aRR:2.9; 95%CI: 2.3, 3.5), hypertension (aRR:2.8; 95%CI: 2.3, 3.4), and asthma (aRR:1.4; 95%CI: 1.1, 1.7), after adjusting for age, sex, and race/ethnicity. Adjusting for the presence of an individual underlying medical condition, higher hospitalization rates were observed for adults aged ≥65, 45-64 (versus 18-44 years), males (versus females), and non-Hispanic black and other race/ethnicities (versus non-Hispanic whites) Conclusion Our findings elucidate groups with higher hospitalization risk that may benefit from targeted preventive and therapeutic interventions

On July 7, 2020, this report was posted online as an MMWR Early Release. Meat and poultry processing facilities face distinctive challenges in the control of infectious diseases, including coronavirus disease 2019 (COVID-19) ( 1 ). COVID-19 outbreaks among meat and poultry processing facility workers can rapidly affect large numbers of persons. Assessment of COVID-19 cases among workers in 115 meat and poultry processing facilities through April 27, 2020, documented 4,913 cases and 20 deaths reported by 19 states ( 1 ). This report provides updated aggregate data from states regarding the number of meat and poultry processing facilities affected by COVID-19, the number and demographic characteristics of affected workers, and the number of COVID-19–associated deaths among workers, as well as descriptions of interventions and prevention efforts at these facilities. Aggregate data on confirmed COVID-19 cases and deaths among workers identified and reported through May 31, 2020, were obtained from 239 affected facilities (those with a laboratory-confirmed COVID-19 case in one or more workers) in 23 states.* COVID-19 was confirmed in 16,233 workers, including 86 COVID-19–related deaths. Among 14 states reporting the total number of workers in affected meat and poultry processing facilities (112,616), COVID-19 was diagnosed in 9.1% of workers. Among 9,919 (61%) cases in 21 states with reported race/ethnicity, 87% occurred among racial and ethnic minority workers. Commonly reported interventions and prevention efforts at facilities included implementing worker temperature or symptom screening and COVID-19 education, mandating face coverings, adding hand hygiene stations, and adding physical barriers between workers. Targeted workplace interventions and prevention efforts that are appropriately tailored to the groups most affected by COVID-19 are critical to reducing both COVID-19–associated occupational risk and health disparities among vulnerable populations. Implementation of these interventions and prevention efforts † across meat and poultry processing facilities nationally could help protect workers in this critical infrastructure industry. Distinctive factors that increase meat and poultry processing workers’ risk for exposure to SARS-CoV-2, the virus that causes COVID-19, include prolonged close workplace contact with coworkers (within 6 feet for ≥15 minutes) for long time periods (8–12 hour shifts), shared work spaces, shared transportation to and from the workplace, congregate housing, and frequent community contact with fellow workers. Many of these factors might also contribute to ongoing community transmission ( 1 ). To better understand the effect of COVID-19 on workers in these facilities nationwide, on June 6, 2020, CDC requested that state health departments report aggregate surveillance data through May 31, 2020, for workers in all meat and poultry processing facilities affected by COVID-19, including 1) the number and type of such facilities that had reported at least one confirmed COVID-19 case among workers, 2) the total number of workers in affected facilities, 3) the number of workers with laboratory-confirmed COVID-19, and 4) the number of COVID-19–related worker deaths. States reported COVID-19 cases determined by the Council of State and Territorial Epidemiologists confirmed case definition. § States were asked to report demographic characteristics and symptom status of workers with COVID-19. Testing strategies and methods for collecting symptom data varied by workplace. Proportional distributions for demographic characteristics and symptom status were calculated for cases among workers in 21 states after excluding missing and unknown values; data were missing for sex in 25% of reports, age in 24%, race/ethnicity in 39%, and symptom status in 37%. States also provided information (from direct observation or from management at affected facilities) regarding specified interventions and prevention efforts that were implemented. A random-effects logistic regression model was used to obtain an estimate of the pooled proportion of asymptomatic (SARS-CoV-2 detected but symptoms never develop) or presymptomatic (SARS-CoV-2 detected before symptom onset) infections at the time of testing among workers who had positive SARS-CoV-2 test results. Five states provided prevalence data from facility-wide testing of 5,572 workers in seven facilities. Modeling was conducted and 95% confidence intervals (CIs) were calculated, with facilities treated as the random effect, using SAS software (version 9.4; SAS Institute). Twenty-eight (56%) of 50 states responded, including 23 (82%) that reported at least one confirmed COVID-19 case among meat and poultry processing workers. Overall, 239 facilities reported 16,233 COVID-19 cases and 86 COVID-19–related deaths among workers (Table 1). The median number of affected facilities per state was seven (interquartile range = 3–14). Among 14 states reporting the total number of workers in affected facilities, 9.1% of 112,616 workers received diagnoses of COVID-19. The percentage of workers with COVID-19 ranged from 3.1% to 24.5% per facility. TABLE 1 Laboratory-confirmed COVID-19 cases among workers in meat and poultry facilities — 23 states, April–May 2020* State Type of meat/poultry in affected facilities No. (%) Facilities affected Workers in affected facilities† Confirmed COVID-19 cases among workers COVID-19–related deaths§ Arizona Beef 1 1,750 162 (9.3) 0 (0) Colorado Beef, bison, lamb, poultry 7 7,711 422 (5.5) 9 (2.1) Georgia Poultry 14 16,500 509 (3.1) 1 (0.2) Idaho Beef 2 797 72 (9.0) 0 (0) Illinois Beef, pork, poultry 26 N/A 1,029 (―) 10 (1.0) Kansas Beef, pork, poultry 10 N/A 2,670 (―) 8 (0.3) Kentucky Pork, poultry 7 7,633 559 (7.3) 4 (0.7) Maine Poultry 1 411 50 (12.2) 1 (2.0) Maryland Poultry 2 2,036 208 (10.2) 5 (2.4) Massachusetts Poultry, other 33 N/A 263 (―) 0 (0) Missouri Beef, pork, poultry 9 8,469 745 (8.8) 2 (0.3) Nebraska Beef, pork, poultry 23 26,134 3,438 (13.2) 14 (0.4) New Mexico Beef, pork, poultry 2 550 24 (4.4) 0 (0) Pennsylvania Beef, pork, poultry, other 30 15,548 1,169 (7.5) 8 (0.7) Rhode Island Beef, pork, poultry, other 6 N/A 78 (―) 0 (0) South Carolina Beef, pork, poultry, other 16 N/A 97 (―) 0 (0) South Dakota Beef, pork, poultry 4 6,500 1,593 (24.5) 3 (0.2) Tennessee Pork, poultry, other 7 N/A 640 (―) 2 (0.3) Utah Beef, pork, poultry 4 N/A 67 (―) 1 (1.5) Virginia Pork, poultry, other 14 N/A 1,109 (―) 10 (0.9) Washington Beef, poultry 7 4,452 468 (10.5) 4 (0.9) Wisconsin Beef, pork, veal 14 14,125 860 (6.1) 4 (0.5) Wyoming Beef 0 N/A 1 (―) 0 (0) Total¶ Beef, bison, lamb, pork, poultry, veal, other 239 112,616 16,233 86 Combined total** ― 264 ― 17,358 91 Abbreviations: COVID-19 = coronavirus disease 2019; N/A = not available. * Data reported through May 31, 2020. Five states that responded to the data request did not report any laboratory-confirmed COVID-19 cases among workers in the animal slaughtering and processing industry; 22 states with animal slaughtering and processing facilities did not respond to the data request. The 13 states that contributed to both an earlier assessment and this update provided any updates to previously reported data, in addition to reporting new cases and facilities, through May 31, 2020. † Among 14 of 23 states reporting the number of workers in affected workplaces, 9.1% of workers received diagnoses of COVID-19. § Percentage of deaths among cases. ¶ Data on workers with COVID-19 from 23 states that submitted data to this report. ** Combining data on workers with COVID-19 (1,125), COVID-19–related deaths (five), and COVID-19–affected facilities (25) through April 27 from six states that contributed to an earlier assessment of COVID-19 among meat and poultry processing workers that did not submit updated data to this report (https://www.cdc.gov/mmwr/volumes/69/wr/mm6918e3.htm?s_cid=mm6918e3_w). Twenty-one states provided information on demographic characteristics and symptom status of workers with COVID-19. Among the 12,100 (75%) and 12,365 (76%) patients with information on sex and age, 7,288 (60%) cases occurred among males, and 5,741 (46%) were aged 40–59 years, respectively (Figure). Among the 9,919 (61%) cases with race/ethnicity reported, 5,584 (56%) were in Hispanics, 1,842 (19%) in non-Hispanic blacks (blacks), 1,332 (13%) in non-Hispanic whites (whites), and 1,161 (12%) in Asians. Symptom status was reported for 10,284 (63%) cases; among these, 9,072 (88%) workers were symptomatic, and 1,212 (12%) were asymptomatic or presymptomatic. FIGURE Characteristics * , † of reported laboratory-confirmed COVID-19 cases among workers in meat and poultry processing facilities — 21 states, April–May 2020 § Abbreviation: COVID-19 = coronavirus disease 2019. * The analytic dataset excludes cases reported by states that were missing information on sex (4,133), age (3,868), race/ethnicity (6,314), and symptom status (5,949). White, black, and Asian workers were non-Hispanic; Hispanic workers could be of any race. † Testing strategies and methods for collecting symptom data varied by workplace. Symptom status was available for a single timepoint, at the time of testing or at the time of interview. § Data reported through May 31, 2020. The figure is a bar chart showing characteristics of reported laboratory-confirmed COVID-19 cases among workers in meat and poultry processing facilities, by sex, age group, race/ethnicity, and symptom status, in 21 states during April–May 2020. Among 239 facilities reporting cases, information on interventions and prevention efforts was available for 111 (46%) facilities from 14 states. Overall, 89 (80%) facilities reported screening workers on entry, 86 (77%) required all workers to wear face coverings, 72 (65%) increased the availability of hand hygiene stations, 70 (63%) educated workers on community spread, and 69 (62%) installed physical barriers between workers (Table 2). Forty-one (37%) of 111 facilities offered testing for SARS-CoV-2 to workers; 24 (22%) reported closing temporarily as an intervention measure. TABLE 2 Interventions and prevention efforts implemented by facilities in response to COVID-19 among workers in 111 meat and poultry processing facilities* —14 states, April–May 2020 † Intervention/Prevention effort COVID-19–affected facilities, no. (%§) Implemented intervention Did not implement intervention Intervention status unknown Worker screening on entry 89 (80) 5 (5) 17 (15) Required universal face covering 86 (77) 5 (5) 20 (18) Added hand hygiene stations 72 (65) 8 (7) 31 (28) Educated employees on community spread 70 (63) 13 (12) 28 (25) Installed physical barriers between workers 69 (62) 17 (15) 25 (23) Staggered shifts 57 (51) 17 (15) 37 (33) Offered SARS-CoV-2 testing to employees¶ 41 (37) 35 (32) 35 (32) Removed financial incentives (e.g., attendance bonuses) 33 (30) 20 (18) 58 (52) Closed facility temporarily 24 (22) 69 (62) 18 (16) Reduced rate of animal processing 23 (21) 14 (12) 74 (67) Decreased crowding of transportation to worksite 17 (15) 10 (9) 84 (76) Abbreviation: COVID-19 = coronavirus disease 2019. * Affected facilities defined as those having one or more laboratory-confirmed COVID-19 cases among workers. † Based on data collected through May 31, 2020. § Because of rounding, row percentages might not equal 100%. ¶ Testing strategies varied by facility. Among seven facilities that implemented facility-wide testing, the crude prevalence of asymptomatic or presymptomatic infections among 5,572 workers who had positive SARS-CoV-2 test results was 14.4%. The pooled prevalence estimated from the model for the proportion of asymptomatic or presymptomatic infections among workers in meat and poultry processing facilities was 11.2% (95% CI = 0.9%–23.1%). Discussion The animal slaughtering and processing industry employs an estimated 525,000 workers in approximately 3,500 facilities nationwide ( 2 , 3 ). Combining data on workers with COVID-19 and COVID-19–related deaths identified and reported through May 31 from 23 states (16,233 cases; 86 deaths) with data from an earlier assessment through April 27 (1,125 cases; five deaths) ( 1 ) that included data from six states that did not contribute updated data to this report, ¶ at least 17,358 cases and 91 COVID-19–related deaths have occurred among U.S. meat and poultry processing workers. The effects of COVID-19 on racial and ethnic minority groups are not yet fully understood; however, current data indicate a disproportionate burden of illness and death among these populations ( 4 , 5 ). Among animal slaughtering and processing workers from the 21 states included in this report whose race/ethnicity were known, approximately 39% were white, 30% were Hispanic, 25% were black, and 6% were Asian.** However, among 9,919 workers with COVID-19 with race/ethnicity reported, approximately 56% were Hispanic, 19% were black, 13% were white, and 12% were Asian, suggesting that Hispanic and Asian workers might be disproportionately affected by COVID-19 in this workplace setting. Ongoing efforts to reduce incidence and better understand the effects of COVID-19 on the health of racial and ethnic minorities are important to ensure that workplace-specific prevention strategies and intervention messages are tailored to those groups most affected by COVID-19. The proportion of asymptomatic or presymptomatic SARS-CoV-2 infections identified in investigations of COVID-19 outbreaks in other high-density settings has ranged from 19% to 88% ( 6 , 7 ). Among cases in workers with known symptom status in this report, 12% of patients were asymptomatic or presymptomatic; however, not all facilities performed facility-wide testing, during which these infections are more likely to be identified. Consequently, many asymptomatic and presymptomatic infections in the overall workforce might have gone unrecognized, and the approximations for disease prevalence in this report might underestimate SARS-CoV-2 infections. Recently derived estimates of the total proportion of asymptomatic and presymptomatic infections from data on COVID-19 investigations among cruise ship passengers and evacuees from Wuhan, China, ranged from 17.9% to 30.8%, respectively ( 8 , 9 ). The estimated proportion of asymptomatic and presymptomatic infections among meat and poultry processing workers (11.2%) is lower than are previously reported estimates and should be reevaluated as more comprehensive facility-wide testing data are reported. In coordination with state and local health agencies, many meat and poultry processing facilities have implemented interventions to reduce transmission or prevent ongoing exposure within the workplace, including offering testing to workers. †† Expanding interventions across these facilities nationwide might help protect workers in this industry. Recognizing the interaction of workplace and community, many facilities have also educated workers about strategies for reducing transmission of COVID-19 outside the workplace. §§ The findings in this report are subject to at least seven limitations. First, only 28 of 50 states responded; 23 states with COVID-19 cases among meat and poultry processing facility workers submitted data for this report. In addition, only facilities with at least one laboratory-confirmed case of COVID-19 among workers were included. Thus, these results might not be representative of all U.S. meat and poultry processing facilities and workers. Second, delays in identifying workplace outbreaks and linking cases or deaths to outbreaks might have resulted in an underestimation of the number of affected facilities and cases among workers. Third, data were not reported on variations in testing availability and practices, which might influence the number of cases reported. Fourth, industry data were used for race/ethnicity comparisons; demographic characteristics of total worker populations in affected facilities were not available, limiting the ability to quantify the degree to which some racial and ethnic minority groups might be disproportionately affected by COVID-19 in this industry. Reported frequencies of demographic and symptom data likely underestimate the actual prevalence because of missing data, which limits the conclusions that can be drawn from descriptive analyses. Fifth, information on interventions and prevention efforts was available for a subset of affected facilities and therefore might not be generalizable to all facilities. Information was subject to self-report by facility management, and all available intervention efforts might not have been captured. Further evaluation of the extent of control measures and timing of implementations is needed to assess effectiveness of control measures. Sixth, symptom data collected at facility-wide testing was self-reported and might have been influenced by the presence of employers. Finally, workers in this industry are members of their local communities, and their source of exposure and infection could not be determined; for those living in communities experiencing widespread transmission, exposure might have occurred within the surrounding community as well as at the worksite. High population-density workplace settings such as meat and poultry processing facilities present ongoing challenges to preventing and reducing the risk for SARS-CoV-2 transmission. Collaborative implementation of interventions and prevention efforts, which might include comprehensive testing strategies, could help reduce COVID-19–associated occupational risk. Targeted, workplace-specific prevention strategies are critical to reducing COVID-19–associated health disparities among vulnerable populations Lessons learned from investigating outbreaks of COVID-19 in meat and poultry processing facilities could inform investigations in other food production and agriculture workplaces to help prevent and reduce COVID-19 transmission among all workers in these essential industries. Summary What is already known about this topic? COVID-19 outbreaks among meat and poultry processing facility workers can rapidly affect large numbers of persons. What is added by this report? Among 23 states reporting COVID-19 outbreaks in meat and poultry processing facilities, 16,233 cases in 239 facilities occurred, including 86 (0.5%) COVID-19–related deaths. Among cases with race/ethnicity reported, 87% occurred among racial or ethnic minorities. Commonly implemented interventions included worker screening, source control measures (universal face coverings), engineering controls (physical barriers), and infection prevention measures (additional hand hygiene stations). What are the implications for public health practice? Targeted workplace interventions and prevention efforts that are appropriately tailored to the groups most affected by COVID-19 are critical to reducing both COVID-19–associated occupational risk and health disparities among vulnerable populations.