The COVID-19 vaccines are coming.
The question is, who gets them first? And who is next in line?
Two companies say that by late November, they expect to have initial results from clinical trials showing whether their vaccines are safe and effective. Several others are not far behind.
But there won't be enough for everyone at first. Hard decisions have to be made about who gets it and who doesn't. So, public health experts are laying out guidelines that aim to do the most good with a limited resource.
Two expert panels have made recommendations already — the U.S. National Academies of Sciences, Engineering, and Medicine and Johns Hopkins University.
But things get complicated quickly.
"When you see these kinds of simple frameworks, they're very important. But the devil's in the details here," said William Moss, executive director of the Johns Hopkins University International Vaccine Access Center.
Front line, front of the line
First in line, experts agree, should be health care workers directly dealing with COVID-19 patients. They're at high risk of infection and they are also critical to keeping society running.
But who, exactly, counts as a health care worker? Doctors and nurses treating COVID-19 patients, clearly. Maintenance workers on the COVID wards, almost certainly. Cooks in nursing homes, possibly. But the farther you get from the bedside, the murkier it gets.
"If you are someone who is an administrator, it depends," said Georges Benjamin, executive director of the American Public Health Association.
For example, maybe office personnel who have patients sign forms should be vaccinated, he said.
It may be up to individual facilities to make the decision.
"We're going to have a committee right here in our own institution to create a staggered system of who should be first, second and third," said Vanderbilt University Medical Center infectious disease professor William Schaffner, "because we are unlikely to get enough doses right on Day 2."
The other group that experts agree should be top priority are patients with health problems that put them at high risk for serious illness and death from COVID-19. That includes people with heart, lung or kidney disease, as well as diabetes and obesity.
But that adds up to more than 100 million people, according to the U.S. Centers for Disease Control and Prevention. The list will likely need to be narrowed further. The National Academies report suggests focusing on people with two or more underlying health conditions.
Next up are workers whose jobs are critical to the functioning of society.
Who is that?
"If you get four people together, you get five opinions," Schaffner said. "There isn't a single correct answer."
Recommendations include teachers, transit workers and people working in the food supply chain. But there is no definitive list.
"It's really hard to know who's in the definition until one is made," said Adriane Casalotti, chief of government and public affairs at the National Association of County and City Health Officers. She said even local health department staff were not automatically considered essential workers.
An expert panel convened by the Centers for Disease Control and Prevention is expected to provide guidance on all the big questions following a meeting next week.
"It will be interesting to see ... how granular they get," Casalotti said.
It is important to have a national framework so everyone feels "that we're all in this together, because it's the only way we're going to make it through the pandemic," she said. Plus, it will help avoid a situation where "you're a local health official who's going to be picking winners and losers."
But there also needs to be flexibility to account for local conditions. The panel has to walk a fine line.
"You run the risk of being too prescriptive and then not prescriptive enough," Casalotti said.
Is my name on the list?
It is one thing to lay out priorities for who should be vaccinated. But how will officials identify the individuals who are eligible and make sure they can get their shots?
"This is really a great question, and this is where I have more concern," Moss said. "We don't have a mechanism for generating a list of people who should get it."
And health officials already struggle to get adults vaccinated for other illnesses. Influenza vaccines rarely reach half the population.
"In a good year, with an established vaccine, it's tough to get shots in the arm," Benjamin said.
But it is doable, he added. Health departments set up drive-thru vaccination centers during the 2009 H1N1 outbreak, for example. And there are plenty of mobile clinics across the country.
"To give someone a vaccination, all you really need is a van and a cooler," he said.
It's not a surprise that so many questions remain, Casalotti said.
"That's, in some ways, the nature of the beast in dealing with this pandemic," she noted. "So much is being done in crisis mode that it takes a lot to work through a lot of these genuine, complicated questions."