On September 1, the National Academies of Sciences, Engineering, and Medicine (NASEM) published its Discussion Draft of the Preliminary Framework for Equitable Allocation of COVID-19 Vaccine.

What’s Most Important?

This draft framework includes recommendations for a tiered prioritization for a COVID-19 vaccine. The top priority group includes front-line health care workers, including those in nursing homes, assisted living and home-based care. It also includes older adults living in “congregate or overcrowded settings,” which the report defines broadly, from residential settings such as nursing homes to more community-based settings such as multigenerational households.  

About the Report

This draft report is designed to provide recommendations as to how a COVID-19 vaccine should be distributed, which population groups should be prioritized and what factors should and should not be considered. The NASEM committee is comprised of physicians, researchers and scientists (see page 100 of the report for a full list). NASEM was not tasked with final decision making through this report but rather making recommendations to other entities, including the Advisory Committee on Immunization Practices (ACIP).

More on Priority Groups

A key part of the NASEM report is the recommendation of a four-tier prioritization of which groups should first have access to the vaccine. These are outlined below. Groups emphasized in bold are of most relevance to aging services providers.

• 1a. Jumpstart phase: high-risk workers in health care facilities, first responders.
• 1b. People of all ages with comorbid and underlying conditions that put them at 1253 significantly higher risk; Older adults living in congregate or overcrowded settings
• 2: Critical risk workers; People of all ages with comorbid and underlying conditions that put them at 1474 moderately higher risk; All older adults not included in Phase 1; People in homeless shelters or group homes for individuals with physical or mental disabilities or in recovery; People in prisons, jails, detention centers, and similar facilities, and staff who work in such settings.
• 3: Young adults; children; workers in industries essential to the functioning of society and at increased risk of exposure not included in Phases 1 or 2.
• 4: Everyone else

Priority Groups and Aging Services

Tier 1 includes high-risk workers in health care facilities and older adults living in congregate or overcrowded settings.

For the workers, this tier includes “front line health care workers (in hospitals, nursing homes, or providing home care) who either: (1) work in situations where risk of SARS-CoV-2 transmission is high, or (2) are at an elevated risk of transmitting the infection to patients at high risk of mortality and severe morbidity.” Workers in this category include both clinical staff and nonclinical staff. In addition to the settings listed in the quote, the report section also mentions assisted living facilities as a high-risk setting. Staff in community-based settings such as adult day services and PACE organizations are not specifically written into this section but might be included if NASEM takes a broad definition of high-risk settings.

For older adults in living in congregate or overcrowded settings, NASEM includes nursing facility residents, residents of residential care facilities and older adults who live below the poverty line. The last category is a proxy for “overcrowded” settings such as multigenerational households. While HUD-assisted/affordable housing communities are not specifically written into the report, most would likely be included in this tier as part of the last category (below the poverty line).

Older adults who do not live in congregate or overcrowded settings are part of the second phase of the recommended framework, unless they have living in “comorbid and underlying conditions” that put them at high risk.

The NASEM report includes a review of the literature for each group to support their placement in the framework. The report takes into consideration the impact of the COVID-19 pandemic on each group to date, known transmission routes (e.g., asymptomatic staff going to nursing homes) and the data on race/ethnicity.

What’s Next?

The NASEM committee that developed the framework is holding a public meeting on September 2 to hear public comments. LeadingAge is scheduled to present our comments at this forum. Our priorities are listed below.

• Support the Tier 1 prioritization of health care workers and older adults in congregate settings.
• Request that older adults in congregate settings to be placed in tier 1a, up from 1b.
• Confirm that “congregate settings” in tier 1b includes affordable/HUD-assisted housing communities.
• Request the community-based setting workers be included in the tier 1a category for workers.

Written public comments will be accepted until September 4 at 11:59 PM EST. Comments can be submitted here: https://www.nap.edu/catalog/25914/discussion-draft-of-the-preliminary-framework-for-equitable-allocation-of-covid-19-vaccine