"This is going to be controversial," he said. "Not everybody is going to like the answer."
Caplan favors an independent commission that includes both scientists and representatives of affected communities, such as people with disabilities and children. Whoever makes the decisions, he said, "it's got to be trustworthy."
Eddy Bresnitz, a former deputy commissioner of the New Jersey Department of Health who is now advising the department on coronavirus response, said he expects that the White House Coronavirus Task Force will also weigh in, but that the ultimate decision will rest with officials at the U.S. Department of Health and Human Services.
The federal government is purchasing vaccines and will allocate them to states, said Bresnitz. States usually have some flexibility in interpreting federal guidance. New Jersey already is planning how the vaccine will be distributed, but that will depend on how many doses are available and characteristics of the vaccine itself.
Nate Wardle, a spokesperson for the Pennsylvania Department of Health, said the commonwealth is preparing to give vaccines to the public and high-risk groups in a variety of settings, including doctors' offices, pharmacies, and other community distribution points that will "ensure the entire population gets the coronavirus vaccination."
Priorities need to consider the multiple public health roles vaccines can play, said William Schaffner, an infectious diseases specialist at Vanderbilt University Medical Center. Typically, younger people mount the strongest immune response, said Schaffner, who represents the National Foundation for Infectious Diseases as a liaison to ACIP. They are currently catching COVID-19 at higher rates and spreading it to other, more vulnerable populations. Vaccinating them could weaken the chain of transmission.
Older people and those with chronic health problems are clearly getting sickest, but vaccines tend to be less effective in these groups. A third group are "the people in society that are responsible for its most essential functions," Schaffner said: medical workers, police and firefighters, those who make, sell and distribute food.
Schaffner said it's important not to create such narrow categories that vaccine sits unused in refrigerators. "Vaccine does not prevent disease," he said. "Immunization prevents disease."
During the H1N1 influenza pandemic in 2009, ACIP developed a five-tiered priority list for vaccine distribution that frames the current discussion. First came critical health care and public health personnel, pharmacists, emergency responders, police and firefighters, along with "deployed personnel." The second tier included essential military support, the National Guard, intelligence services and other national security personnel as well as mortuary workers, and those in communications, IT and utilities. High-risk adults were in the fourth tier and healthy adults, aged 19 to 64 were in the last group.
Children were a high priority in that plan, because H1N1 hit them harder. They will be a lower priority this time, Schaffner said, because they are not involved in current vaccine trials. In addition, young children seem to be less likely to spread the virus than older children or adults. Older children rarely develop serious complications. Pregnant women, however, could remain a high-priority group.