Opinion | Find Your Place in the Vaccine Line

By Stuart A. Thompson

A vaccine may be around the corner, but how long will it be until you get the shot? Health officials are considering vaccine timelines that give some Americans priority over others. If you’re a healthy American, you may wait many months for your turn.

To put this in perspective, we worked with the Surgo Foundation and Ariadne Labs using their vaccine tool to calculate the number of people who will need a vaccine in each state and county — and where you might fit in that line.

To start, tell us about yourself:

Based on your risk profile, we believe you’re in line behind people across the United States.

When it comes to , we think you’re behind others who are at higher risk in your state.

And in , you’re behind others.

If the line in was represented by about 100 people, this is where you’d be standing:

The article continues below the graphic.

The order outlined above is one possibility, combining proposals by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention alongside a fuller proposal by the National Academies of Sciences, Engineering and Medicine.

The final order is not yet determined and depends on successful vaccines being adequately tested for every group. Children might be skipped if early vaccines aren’t approved for people under 18. States could also set their priorities, but will most likely follow the final C.D.C. recommendations.

How quickly we’ll move through the final line is also an open question.

While millions of health care workers in the country could be vaccinated this month, the most prominent vaccine candidates require an ultracold distribution chain that can’t yet reach every American. States also need to procure even more personal protective equipment and set up socially distanced mass-vaccination sites amid a pandemic that could slow everything down.

“It’s incredible that we have vaccines with high levels of initial efficacy in such a short period of time,” said Dr. Sema Sgaier, a co-founder and the executive director of the Surgo Foundation.

“But the vaccine is not going to be a silver bullet for a while,” she added.

Health care workers

and nursing homes

Essential workers, first responders, adults

with Covid-19 health risks, other elderly

Young adults,

children, lower-risk

essential workers

Health care workers

and nursing homes

Essential workers,

first responders, adults

with Covid-19 health

risks, other elderly

Young adults, children,

lower-risk essential workers

Source: Advisory Committee on Immunization Practices; the National Academies of Sciences, Engineering and Medicine.

The rollouts are based on who’s most at risk and how we can most effectively lower transmission and reduce deaths. Adults aged 18 to 30 should come earlier, NASEM recommended, because they may be responsible for more asymptomatic transmission.

It’s possible enough vaccine could be available after the first few months to skip phases altogether and start vaccinating everyone. But any delay in approvals, manufacturing or distribution could mean giving some Americans priority over others for much of next year.

“I don’t think there’s anyone in public health who thinks we have the human capacity and the logistical capacity to handle everyone in just a few months,” said Dr. William Schaffner, a professor of infectious diseases at the Vanderbilt University School of Medicine.

And in a country as divided as America, it seems inevitable that the process will get politicized. The idea that some of us should take precedence over others is likely to run up against America’s me-first libertarian streak, the same one that flouted mask-wearing laws and rejected scientific recommendations in favor of conspiracy theories and rumor.

Several groups, including the American Medical Association, have argued that the 2.3 million incarcerated people should be vaccinated before other healthy Americans. That’s for good reason: People in prison have a 5.5-fold greater risk of developing Covid-19, according to a study of state and federal prisons. It’s also often impossible to practice social distancing in prison.

An outbreak in a prison or jail also spreads easily to the community. One study found that by mid-April, roughly one in six coronavirus cases in Illinois were linked to people released from Cook County Jail.

The idea that prisoners could get vaccinated before average Americans is already facing pushback. “There’s no way it’s going to go to prisoners before it goes to people who haven’t committed any crime,” Gov. Jared Polis of Colorado said this week.

“Whichever criteria people choose, there will always be someone not happy with it,” Dr. Sgaier said. “We should definitely expect pushback and people unhappy with the process. That’s going to be political.”

The prioritization will seem especially pronounced in states with a larger share of incarcerated and high-risk Americans, including many Southern states, like Alabama, Louisiana, Texas and Mississippi. Healthy Americans there may have to wait.

62% of people in East Carrol Parish, La.,

have Covid-19 comorbidities, are homeless

or are incarcerated

57%

Issaquena County, Miss.

20% of people in Douglas County, Colo.,

have Covid-19 comorbidities,

are homeless or are incarcerated

62% of people in East Carrol Parish, La.,

have Covid-19 comorbidities, are homeless

or are incarcerated

57% in Issaquena County, Miss.

20% of people in Douglas

County, Colo., have Covid-19

comorbidities, are homeless

or are incarcerated

Note: Share among groups considered in phased vaccine rollout. Source: Surgo Foundation and Ariadne Labs

Even when there is enough vaccine to reach all Americans, the particulars are murky. Healthy adults working from home have lower risk, so they may get vaccinated after people who commute, according to a recommendation by the National Academies of Sciences, Engineering and Medicine. If quantities are limited for longer than a few months, a lottery might be necessary, the group warned.

And, of course, all this depends on getting a vaccine where it needs to go.

It’s hard to grasp how complicated the rollout will be. For every 100 doses, providers will need 105 needles and syringes of varying sizes, 210 alcohol prep pads, 4 surgical masks, 2 face shields and 100 vaccine report cards to track patients’ vaccine histories, according to the C.D.C. That equipment must be manufactured, packaged and shipped to coincide with vaccine deliveries.

“The whole delivery process is humongous,” said Vijay Samant, a former head of vaccine manufacturing for Merck. “I don’t think you’ll make a meaningful vaccination impact in the first six months.”

The logistical challenges don’t end there. Washington State, for instance, indicated it would need up to 20,000 pounds of dry ice — for the first two months of vaccinations alone.

And since the most promising vaccines require two doses, twice as much equipment is needed for a full vaccination, when people will return for a second dose 21 to 28 days later.

“This is a completely impractical vaccine,” Mr. Samant said. “But we're in an impractical scenario right now, so whatever works, works.”

For Mr. Samant, who worked in the vaccine business for more than 25 years, the challenge seemed mammoth. He compared it with the chickenpox vaccine, which also required a new cold storage chain when it was released in 1995. Merck purchased freezers for pediatric practices as part of a complex rollout plan.

“What a remarkable effort that was, and it was planned for at least 18 months before the launch took place,” he said.

This time, states have only weeks to get ready.

Most have released vaccination plans outlining how they’ll acquire and distribute the vaccines. Some have started partnering with providers that can dole out vaccines, while others are still developing those plans, according to a Kaiser Family Foundation review.

“Some states are going to do a hell of a lot better than other states,” said Gordon Douglas, former president of Merck’s vaccine division. “That’s unfortunately the truth.”

Plans from Idaho, West Virginia and Alabama contain few details compared with those of states like California and Maryland. Colorado’s plan, for instance, runs over 100 pages long; Montana’s is 35.

The logistical challenges are made worse by the storage requirements for the two leading vaccines, both of which must be stored at ultracold temperatures – one at minus 80 degrees Celsius. (A third vaccine, by AstraZeneca and the University of Oxford, which had more questionable early results, uses more familiar technology that would be easier to roll out.)

“Distributing something that has to be refrigerated at minus 80 — it can be done, people know how to make freezers,” said Fred Ledley, a professor of natural biology and applied sciences at Bentley University. “But it’s very expensive.” And your local pharmacy can’t do it yet.

It will be comparatively easy to vaccinate health care workers and first responders in hospitals where they work. But it will take time to reach other essential workers and even longer for the general population.

Expect long lines snaking around the corner at your local community center or school gymnasium. Think of what it looks like during a typical election.

That’s an ominous comparison when you consider how conspiracy theorists and partisans seized on minor issues at polling sites this election as proof of widespread fraud. And like Election Day, a national vaccination rollout will involve thousands of people working under a microscope. Every little mistake could be twisted into proof that the vaccines shouldn’t be trusted.

“You’re talking about people making errors in counting votes, which is so easy, black and white,” Mr. Samant said. “And here you’re asking people to deliver a two-dose vaccine, which is a far more complex process.”