Public Perspectives on COVID-19 Vaccine Prioritization

Key Points Question Which groups does the public believe should be prioritized for COVID-19 vaccine access? Findings In this survey study of 4735 US adults, respondents of all demographic and political affiliations agreed with prioritizing health care workers, adults of any age with serious comorbid conditions, frontline workers (eg, teachers and grocery workers), and Black, Hispanic, Native American, and other communities that have been disproportionately affected by COVID-19. Older adult respondents were less likely than younger respondents to list healthy people older than 65 years as 1 of their top 4 priority groups. Meaning These findings suggest that the US public agrees with the high-priority groups proposed by the National Academies of Science, Engineering, and Medicine but appears to disagree with approaches advanced by others that prioritize older adults but not essential workers or disproportionately affected communities.


Introduction
Since the US Food and Drug Administration's issuance of emergency use authorizations for the Pfizer-BioNTech and Moderna COVID-19 vaccines, mass vaccination efforts have begun across the US. 1 Because demand for COVID-19 vaccines exceeds the supply, phased distribution has been necessary, and prioritization, and targeted outreach will likely continue even once eligibility is open to all. The Centers for Disease Control and Prevention's (CDC) Advisory Committee on Immunization Practices (ACIP) has-largely consistent with the distribution plan set forth in the National Academies for Science, Engineering, and Medicine's (NASEM) Preliminary Framework for Equitable Allocation of COVID-19 Vaccine-recommended that health care personnel and long-term care facility residents receive the initial doses (phase 1a), followed next by people older than 75 years and frontline workers (phase 1b), and then by people aged 65 to 74 years, those with high-risk medical conditions, and other essential workers (phase 1c). [2][3][4][5] Federal, state, local, and tribal jurisdictions are drawing on, but often varying from, these nonbinding CDC ACIP recommendations to plan and implement distribution. [6][7][8] In fact, access to COVID-19 vaccination has proven highly dependent on where one lives, as distribution plans continue to evolve and to diverge from both CDC ACIP recommendations and from one another. 9 With COVID-19 vaccination underway, policy makers are confronting numerous open questions about how to allocate vaccines. What should be the relative prioritization of essential workers, healthy older adults, and people with high-risk medical conditions? 4 Should prisoners and prison guards be prioritized before grocery store workers? 10 Should socioeconomically disadvantaged communities disproportionately affected by COVID-19 receive priority? 11 What about COVID-19 vaccine trial participants who received a placebo? 12 Although public opinion does not determine right and wrong, public engagement can aid in answering questions like these, help to identify gaps between public values and proposed prioritization schemes, and estimate the perceived legitimacy of allocation policies. 13,14 Public views can be particularly helpful in prioritization between groups that are otherwise equally ranked on ethical grounds. Prior surveys [15][16][17] have examined preferences regarding scarce resource allocation in the pandemic, but few have focused specifically on COVID-19 vaccine allocation. To address this gap, we surveyed 2 representative samples of US adults about COVID-19 vaccine allocation priorities.
Our study builds on prior surveys in key ways. First, we required respondents to rank priority groups comparatively, which more accurately reflects vaccine allocation under conditions of scarcity.
Second, we disaggregated certain essential workers, such as teachers, restaurant workers, and grocery store workers. Third, we surveyed attitudes toward different allocation considerations or principles focused specifically on vaccines, rather than on scarce resources broadly.

Gallup COVID-19 Panel
From September 14 to 27, 2020, Gallup conducted a nationwide online survey, in English, of US adults aged 18 years and over. The Gallup COVID-19 Panel is a probability-based panel of US adults selected using address-based sampling methods and random-digit-dial telephone interviews that cover landline and cellular telephones. Using Current Population Survey data, the study sample was weighted by age, gender, race/ethnicity, education, and US Census region, to be demographically representative of the US adult population. The survey achieved a response rate of 39% using the American Association for Public Opinion Research Response Rate Calculation (AAPOR RR 1). Gallup offered survey respondents $1 for completing the survey. The survey questions are shown in eAppendix 1 in the Supplement.

COVID Collaborative
From September 19 to 25, 2020, Hart Research conducted a nationwide online survey, in English, among US adults aged 18 years and older on behalf of the COVID Collaborative, a national collaboration of experts in health, education, and economics focused on developing consensus recommendations related to the COVID-19 pandemic. Respondents were recruited from an online opt-in, nonprobability panel. Quotas were set and slight weights were applied to ensure that the sample was representative of adults overall and within subgroups by key demographic variables. The survey achieved a participation rate of 93% (defined as the number of completed surveys, terminates, or over quota, divided by the number of respondents who entered the survey) and a completion rate (completed surveys divided by number of respondents who entered the survey) of 42%. The AAPOR RR1 is not applicable, as the number of people presented with the survey in the opt-in panel is not known. Hart Research offered respondents an incentive that averaged $1.57 per

Statistical Analysis
Respondents' answers were compared using χ 2 tests accounting for survey weights ( ranked "people with serious medical conditions that make them more likely to have complications or die from COVID-19" among their top 4 priority groups. Older respondents were less likely to prioritize healthy people older than 65 years for vaccination (eTable 1, eTable 2, and eTable 3 in the Supplement). Respondents in both surveys aged 65 years and older were significantly less likely than those younger than 65 years to rank healthy adults aged 65 and older among their 4 highest priority groups (Gallup, 23.7% vs 39.1% [χ 2 = 2160.8; P < .001]; COVID Collaborative, 23.3% vs 28.8% [χ 2 = 5.0198; P = .03]). There was substantial agreement between survey respondents' highest priorities for vaccine distribution and NASEM's and ACIP's phased COVID-19 vaccine distribution plans ( Table 3).

Considerations for Prioritization
Only COVID Collaborative respondents were asked to "select the four considerations you think should be most important" when deciding who should be vaccinated first. The 4 most commonly selected considerations were "focus on what will most prevent the spread of the virus" (78.4%; 95%

Highest Priority Groups
First, across both surveys, most respondents prioritized health care workers for COVID-19 vaccination. Majorities of respondents also ranked nursing home residents and staff, as well as adults Importantly, older respondents were less likely to prioritize themselves for COVID-19 vaccine access. This departs sharply from prior findings, 15 which indicated that older people were likelier to prioritize themselves for vaccination. The difference could reflect the fact that our questionsfollowing NASEM's language-distinguished healthy adults older than 65 years from medically vulnerable adults and those in nursing homes. Consistent with other studies, we found that respondents of color were likelier than White respondents to accept priority for young children, teens, and adults younger than 65 years. Recent findings that middle-aged adults face substantial risk from COVID-19 and that risk for younger and middle-aged patients is disproportionately higher in Respondents agreed with many of NASEM's occupational rankings, giving highest priority to teachers and childcare workers, then to grocery store workers, and finally to workers at restaurants, bars, and gyms. Notably, more respondents endorsed prioritization of teachers and childcare workers than healthy adults aged 65 years or older or grocery store workers, which has implications for their relative prioritization within NASEM's phase 2 and ACIP's phase 1b. 3,25 This preference aligns with ethical arguments that reopening schools and allowing undisrupted learning without parental supervision is important for equity and benefit to children and their families and conflicts with recent state choices to rank teachers and other childcare workers behind healthy older adults. 26

Prioritization to Address Health Inequities
Third, given the national discussion-and sometimes disagreement-about systemic racism and its relevance to the COVID-19 pandemic, 27  Island elected to focus early vaccine access on one such community, 29 and other states and localities have used zip codes or vulnerability indices to prioritize vaccine distribution. 30,31 Our findings suggest that US adults endorse vaccine allocation policies and implementation strategies that achieve priority access for Black, Hispanic, Native American, and other communities who have experienced high numbers of COVID-19 cases, as well as more and earlier deaths. They also imply that an important part of messaging will be to emphasize the COVID-19 burden borne by these groups as the reason for their prioritization. Importantly, policies that explicitly recognize and address population-level racial disparities without classifying individual beneficiaries by race have been upheld in court in other contexts 32 and have been implemented and upheld for other aspects of COVID-19 response. 33,34 Whether prisoners should be given priority for vaccination has also been prominently discussed because prisons are high-risk settings for COVID-19 spread. 30 Some states, such as Massachusetts, have given prisoners priority whereas others, such as Colorado, have not. 35 NASEM placed prisoners and prison guards in phase 2, along with teachers, grocery store workers, and healthy older adults.
A majority of survey respondents accept some degree of priority for prisoners, disagreeing with Colorado's denial of priority. However, respondents appear less willing to prioritize prisoners and prison guards than other phase 2 groups. This may indicate that people convicted of crimes are perceived as less deserving of COVID-19 vaccines than others at similar risk, paralleling survey responses in other contexts. 36,37 Fourth, respondents' answers could also inform current debates over whether COVID-19 vaccine trial participants who received placebos should now be prioritized for vaccination. 38 Although COVID Collaborative respondents were comfortable with people who participated in COVID-19 research preceding them in line, only one-quarter ranked research participants among their 4 highest-priority groups. This suggests potential public support for an intermediate approach, such as allowing trial participants to precede others within the same group (eg, among essential workers). 39

Considerations for Prioritization
Fifth, respondents' top considerations for prioritization largely tracked NASEM's ethical framework, rather than a single-principle approach of maximizing near-term lives saved directly by vaccination.
Preventing spread of the virus and preventing death aligns with the principle of maximum benefit.
Protecting frontline workers-who are likelier to be lower-paid and members of groups subject to structural discrimination-and disproportionately impacted communities aligns with mitigation of health inequities. 2

Limitations
Generalizing survey results to the population of interest is based on the assumption that respondents are a representative sample of the population; given our response rates, it is possible that there was nonresponse error and our survey estimates may be biased. Conducting the survey in English omitted some segments of the US population. In addition to sampling error, question wording and difficulties in conducting online surveys can introduce error and bias into the findings of public

Conclusions
The findings of these 2 surveys of US adults suggest that members of the US public agreed with core elements of NASEM's and ACIP's COVID-19 phased vaccine distribution plans. They also endorsed prioritizing disproportionately affected communities, including communities of color. Respondents differed with government bodies and officials regarding purely age-based prioritization and strongly endorsed priority for teachers and childcare workers. Particularly noteworthy was older respondents' lesser support for prioritizing healthy people older than 65 years and respondents' greater support for prioritizing younger and middle-aged recipients. These findings indicate that the public would be supportive of prioritization approaches that effectively recognize multiple values, rather than basing allocation solely on age or any other single factor. Policy makers should build on existing efforts, such as proactive outreach to vulnerable communities and workplaces, and commit to investing resources to achieve vaccine distribution that is both speedy and consonant with public values.

ARTICLE INFORMATION
Accepted for Publication: March 7, 2021.