Who will get the first doses of a coronavirus vaccine? Johns Hopkins experts have some ideas

The development of vaccines for the coronavirus is moving along, but there is widespread agreement among public health officials that there won’t be enough doses initially for everyone.

How should the initially scarce, potentially life-saving vaccines be distributed? The Johns Hopkins Center for Health Security released a suggested framework for vaccine distribution, though the decision will be up to the federal government, which is buying several hundred million doses.


There are 165 vaccine candidates globally, and one or more could be approved soon on an emergency basis, according to the team of Hopkins researchers who contributed to the report. Deciding who gets those early supplies is a “difficult and potentially contentious” topic.

The people who should be first in line for vaccination include those essential to the COVID-19 response such as health care and emergency workers, the Hopkins experts suggested. That first tier also should include those at greatest risk of severe illness such as seniors and their caregivers and those who maintain core societal functions, including teachers and food and transit workers.


The report, called an “ethics framework” and not direct recommendations, addresses only priority groups and not the general population. It aims to give greater attention to groups that may have been overlooked in past pandemic planning and consider racial and ethnic disparities. It also recognizes essential workers.

The effort comes as distribution is being discussed in the U.S. Center for Disease Control and Prevention’s Advisory Committee on Immunization Practices, which makes vaccine recommendations, and in other U.S. and global centers.

The conclusions are aimed at policymakers at the federal and local levels, as well as the general public. The guidance is likely to change over time and as more is learned about the pandemic, but the report says the framework “could serve as a conceptual resource to inform the design and execution of a timely national dialogue.”

The report contributors, from across the Johns Hopkins University, say they considered medical risk, public health, ethics and equity, economic impact and logistics. They also looked at the CDC’s pandemic flu vaccine guidance.

The federal government, through its Operation Warp Speed vaccine development program, plans to pre-buy 300 million doses of vaccine and distribute them when they become available. It’s already made some deals, including with the vaccine makers Pfizer and Moderna, for doses of their products if they are approved.

It’s not clear which vaccines will prove safe and effective and gain federal approval first, though about a half dozen candidates globally are in late-stage trials. One or more could be approved by year’s end or early next year.

The U.S. Department of Health and Human Services says it plans a tiered approach to vaccine distribution that was built on past pandemic flu planning, though officials say there will be adjustments “based on experience during the first wave of the COVID-19 response, data on the virus and its impact on populations and the performance of each vaccine, and the needs of the essential workforce.”

The main focus of any plan should be fairness, said Diane E. Hoffmann, a professor of health law at the University of Maryland Carey School of Law and director of the Maryland Health Care Ethics Committee Network.


“Whatever allocation plan is adopted it needs to be transparent and perceived as fair by most of the general public,” said Hoffmann, who had not yet seen the Hopkins report.

“The issue is fraught with potential controversy regarding who should get priority,” she said. “The federal government needs to take a leadership role and the public needs to trust that the plan will be implemented fairly without favoritism and side deals that undermine the process.”

The tiers outlined in the Hopkins report are not controversial, said Tinglong Dai, an associate professor of operations management and business analytics in Hopkins’ Carey Business School.

But scarce early supplies could lead to some politicizing, said Dai, who was not involved in the report but had reviewed it.

“I have no doubt the process will be politicized to some extent,” he said.

“Few people would question the tier-1 status of front-line health care workers, the elderly and those with underlying conditions,” he said. “However, the prioritization becomes less clear when it comes to other groups such as essential workers. To determine whether one group is more ‘essential’ than another is a tricky task. Are police officers more or less essential than firefighters?”


He also noted the guidelines do not include young children in the top tier, which is justified by their lower risk, but “might not be particularly well received.”

Dai said people with means might try to jump the line, though given some people’s hesitancy to accept vaccines, they also might seek protection by vaccinating those around them.

Such hesitancy is real, studies have found, posing another potential challenge.

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A study released Thursday by the University of Pennsylvania’s Annenberg Public Policy Center, which polled people during last year’s measles outbreak, found strong support for vaccines. But up to 20% held negative views, which it largely attributed to misinformation about safety.

“There are real implications here for a vaccine for COVID-19,” said Dominik Stecula, the study’s lead author who is now an assistant professor of political science at Colorado State University, in a statement. “There needs to be an education campaign by public health professionals and journalists, among others, to preemptively correct misinformation and prepare the public for acceptance of a COVID-19 vaccine.”

The Hopkins report stuck to the issue of scarcity, saying that there likely won’t even be enough vaccines initially for everyone in the top priority tier, and people within that group likely would have to be prioritized. That could be done by considering the people’s ability to protect themselves, their ages and the importance of their jobs.


The report also identifies a potential second tier for vaccination. It includes general health and pharmacy workers and those who lack access to care such as people in rural communities or reservations. It also includes those who work in public water and sanitation systems and other essential services such as police and military.

This group also includes those who must go to work and can’t distance themselves and those who live in shelters or prisons.

The report says what’s done early in a vaccination campaign will affect confidence in government and the health care system, so the effort needs to be done appropriately and “clearly communicated.”

“If, on the other hand, an allocation strategy is ethical, nationally consistent, fair and informed by key constituency groups,” the report concludes, “then the vaccination campaign is more likely to go smoothly and be accepted by the public, which would result in many lives saved and faster economic recovery.”