When COVID vaccine is finally rolled out, who gets it first?

President Donald Trump says a coronavirus vaccine will be approved within weeks. Health experts say several months is more likely.

Approval is one thing. Producing enough vaccine so everyone can be vaccinated is quite another. The chief of the world’s largest vaccine manufacturer, the Serum Institute of India (SSI), says that will take four or five years.

Any safe, effective vaccine against COVID-19 will be in short supply until production ramps up. In the meantime, who’s first in line to get vaccinated?

Plans are still being worked out. Each country or organization will have to determine whom it immunizes initially and how the vaccine will be distributed, said Sir Mene Pangalos, executive vice president of pharma giant AstraZeneca, in an interview with the BBC.

In the United States, a five-phase approach drafted in September by a panel assembled by the U.S. National Academies of Sciences, Engineering and Medicine (NASEM), strives to fairly allocate limited supplies of a vaccine to U.S. residents:

Phase 1: Health care workers and first responders (5% of the U.S. population)

Phase 2: People with underlying medical conditions that put them at high risk of severe COVID-19 disease or death, and older adults in densely populated settings like nursing homes (10%)

Phase 3: Essential service workers at high risk of exposure, teachers and school staff, inmates and prison staff, people in homeless shelters, older adults who have not already been treated, people with underlying medical conditions facing moderate risk (30-35%)

Phase 4: Young adults, children and essential service workers at increased risk of exposure (40-45%)

Phase 5: All remaining residents (5-15%)

(Note: Phases 1 and 2 could occur in tandem.)

Last month the World Health Organization also released a guidance for a global vaccine allocation that is still in its early stages. It lists which groups should have priority access.

The U.S. hopes to get 300 million doses, with the first doses available by January, through its fast-track vaccine program, Operation Warp Speed.

Meanwhile, the WHO, epidemic response group CEPI and Gavi, the Vaccine Alliance of governments and organizations, have been pooling resources to ensure that rich countries don’t monopolize vaccine stocks at the expense of poorer nations. Through their COVAX plan, they are hoping to raise about $2 billion to support the speedy development of a vaccine and ensure its equitable distribution worldwide. Their goal is 2 billion doses for vulnerable countries by the end of 2021.

At least 80 wealthy nations and economies have joined the COVAX effort. The United States is not among them.

The Gavi plan parallels the NASEM guidance, with health workers getting the first dibs on a vaccine (3% of a country’s population) and the over-65s and high risk groups next in line (20%). No country will receive enough doses to vaccinate more than 20 percent of their population until all nations in the group have been offered that amount.

The cost of an individual vaccine dose could vary widely.

SSI is being bankrolled with $150 million from Gavi and the Bill & Melinda Gates Foundation to make and deliver up to 100 million doses of successful vaccines to India and low- and middle-income countries. The ceiling price for a dose is estimated at $3, but few patients are likely to be charged.

Australia says the vaccines it administers to its people will be free.

Pharmaceutical company Moderna is reportedly selling access to its potential vaccine at between $32 and $37 a dose, according to the BBC.

Some Americans may have to pay out of pocket to be inoculated if they are uninsured or enrolled in a plan requiring a co-pay.

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