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Prioritization of pregnant individuals in state plans for coronavirus disease 2019 vaccination

Published:March 13, 2021DOI:https://doi.org/10.1016/j.ajog.2021.03.015

      Objective

      The US Centers for Disease Control and Prevention (CDC) considers pregnant people to be at high-risk for severe disease and death from coronavirus disease 2019 (COVID-19), and the Advisory Committee on Immunization Practices (ACIP) recommends that pregnant individuals should be prioritized for vaccination in Phase 1c of vaccine allocation.
      • Dooling K.
      • Marin M.
      • Wallace M.
      • et al.
      The Advisory Committee on Immunization Practices’ updated interim recommendation for allocation of COVID-19 vaccine—United States, December 2020.
      However, various state vaccination plans have not been uniform in the adoption of the ACIP priority group recommendations. Prior research found 15 states included pregnancy among other COVID-19 priority groups,
      • Grünebaum A.
      • McCullough L.B.
      • Litvak A.
      • Chervenak F.A.
      Inclusion of pregnant individuals among priority populations for coronavirus disease 2019 vaccination for all 50 States in the United States.
      but planning has been highly dynamic in recent weeks. The objectives of this study were to determine how many states prioritize pregnant individuals for COVID-19 vaccination and assess the current eligibility of pregnant people to receive COVID-19 vaccinations across the United States.

      Study Design

      We searched for information about the priority groups for COVID-19 vaccinations from all 50 states in the United States and the District of Columbia on March 6, 2021. Our analysis included information from official government websites. This study did not require institutional review board approval because it examined data from publicly available sources and used no patient information.

      Results

      As of March 6, 2021, most states (36 of 51; 73%) classified pregnant individuals as a priority group for COVID-19 vaccination; in just under 50% of the states (24 of 51), pregnant people are currently eligible for vaccination (Table). The 36 states prioritizing pregnancy encompass 76% of the US population. Of these states, 23 refer to the CDC’s classification of pregnant people as being at an elevated risk for severe COVID-19 illness. Several states (9 of 51; 18%) prioritize groups at elevated risk for severe COVID-19 illness because of preexisting health conditions but have not specifically enumerated pregnant people as a priority group. Four states have designed their prioritization plan around an age-descending strategy, and 2 states list only current or near eligible groups, and pregnant people are not included.
      TableState prioritization of pregnant individuals for coronavirus disease 2019 vaccination
      StatePriority (phase)
      Phase listed refers to the first phase or subphase in which pregnant individuals are prioritized for vaccination. These have been rounded to the nearest subphase when divided into subphase tiers. States which do not follow a clear, phased approach to vaccination but still prioritize pregnant individuals are listed only as “Yes.” When pregnant individuals are prioritized across multiple phases, they are listed here under the earliest phase in which they are enumerated
      Current eligibility
      Eligibility varies in some states at the county level. Results here refer to eligibility of pregnant individuals in at least some counties within a state, even if there are additional requirements such as multiple, high-risk health states or an age threshold. States were not enumerated if they rely on reference from a physician to determine vulnerability to COVID-19 without specific mention of pregnancy
      Population
      Population counts obtained from 2019 US Census Bureau Data (https://www.census.gov/newsroom/press-kits/2019/national-state-estimates.html)
      Source
      AlabamaYes (1c)No4,903,185https://www.alabamapublichealth.gov/covid19vaccine/distribution.html
      AlaskaYes (1b)Yes731,545http://dhss.alaska.gov/dph/epi/id/pages/COVID-19/vaccine.aspx
      Arizona
      At the time of plan analysis, Arizona was transitioning toward an age-based approach to COVID-19 vaccine eligibility and not all government resources had been updated to reflect this policy adjustment. Our analysis reflects the anticipated age-based approach.
      NoNo7,278,717https://azgovernor.gov/governor/news/2021/03/state-adopts-unique-hybrid-model-covid-19-vaccine-prioritization
      ArkansasYes (1c)No3,017,804https://www.healthy.arkansas.gov/programs-services/topics/covid-19-vaccination-plan
      CaliforniaYes (1c)No39,512,223https://covid19.ca.gov/vaccines/#California's-vaccination-plan
      ColoradoYes (1b)Yes5,758,736https://covid19.colorado.gov/for-coloradans/vaccine/vaccine-for-coloradans
      ConnecticutNoNo3,565,287https://portal.ct.gov/vaccine-portal/COVID-19-Vaccination-Phases
      DelawareNoNo973,764https://coronavirus.delaware.gov/vaccine/vaccination-timeline/#phase-1b
      FloridaNoNo21,477,737https://floridahealthcovid19.gov/covid-19-vaccines-in-florida/
      GeorgiaNoNo10,617,423https://dph.georgia.gov/covid-vaccine
      HawaiiNoNo1,415,872https://hawaiicovid19.com/vaccine/#first-vaccines
      IdahoNoNo1,787,065https://healthandwelfare.idaho.gov/covid-19-vaccination
      IllinoisYes (1b+)Yes12,671,821https://www.dph.illinois.gov/covid19/vaccine-distribution
      IndianaNoNo6,732,219https://www.coronavirus.in.gov/vaccine/index.htm
      IowaYes (1b)Yes3,155,070https://idph.iowa.gov/Emerging-Health-Issues/Novel-Coronavirus/Vaccine/Information-for-the-Public
      KansasYes (3)No2,913,314https://www.kansasvaccine.gov/157/Availability
      KentuckyYes (1c)Yes4,467,673https://govstatus.egov.com/ky-covid-vaccine
      LouisianaYes (1b)Yes4,648,794https://ldh.la.gov/index.cfm/faq/category/138
      MaineNoNo1,344,212https://www.maine.gov/covid19/vaccines/phases
      MarylandNoNo6,045,680https://covidlink.maryland.gov/content/vaccine/
      MassachusettsYes (2)Yes6,892,503https://www.mass.gov/info-details/covid-19-vaccinations-for-individuals-with-certain-medical-conditions
      MichiganYes (1c)No9,986,857https://www.michigan.gov/documents/coronavirus/MI_COVID-19_Vaccination_Prioritization_Guidance_2152021_716344_7.pdf
      MinnesotaYes (1b)No5,639,632https://www.health.state.mn.us/diseases/coronavirus/vaccine/phase1b1c2.pdf
      MississippiYesYes2,976,149https://msdh.ms.gov/msdhsite/_static/14,22816,420,976.html
      MissouriYes (1b)Yes6,137,428https://covidvaccine.mo.gov/priority/Phase1b/#phase1b-2
      MontanaNoNo1,068,778https://dphhs.mt.gov/publichealth/cdepi/diseases/coronavirusmt/covid19vaccineavailability
      NebraskaNoNo1,934,408https://dhhs.ne.gov/Pages/COVID-19-Vaccine-Information.aspx#SectionLink2
      NevadaYesYes3,080,156https://www.immunizenevada.org/county-specific-covid-19-vaccine-plan
      New HampshireYes (1b)Yes1,359,711https://www.dhhs.nh.gov/dphs/cdcs/covid19/documents/covid19-vaccine-allocation-plan-summary.pdf
      New JerseyYes (1b)Yes8,882,190https://covid19.nj.gov/faqs/nj-information/slowing-the-spread/who-is-eligible-for-vaccination-in-new-jersey-who-is-included-in-the-vaccination-phases
      New MexicoYes (1b)Yes2,096,829https://cv.nmhealth.org/wp-content/uploads/2021/02/2021.1.28-DOH-Phase-Guidance.pdf
      New YorkYes (1b)Yes19,453,561https://covid19vaccine.health.ny.gov/phased-distribution-vaccine#phase-1a---phase-1b
      North CarolinaYes (group 4)No10,488,084https://covid19.ncdhhs.gov/vaccines/providers/covid-19-vaccine-management-system-cvms
      North DakotaYes (1b)Yes762,062https://www.health.nd.gov/covid-19-vaccine-priority-groups
      OhioYes (1c)Yes11,689,100https://coronavirus.ohio.gov/wps/portal/gov/covid-19/covid-19-vaccination-program
      OklahomaNoNo3,956,971https://oklahoma.gov/covid19/vaccine-information.html
      OregonYes (1b)Yes4,217,737https://sharedsystems.dhsoha.state.or.us/DHSForms/Served/le3527A.pdf
      PennsylvaniaYes (1a)Yes12,801,989https://www.health.pa.gov/topics/disease/coronavirus/Vaccine/Pages/Distribution.aspx
      Rhode IslandYesNo1,059,361https://health.ri.gov/publications/guidelines/COVID19-underlying-conditions.pdf
      South CarolinaYes (1b)No5,148,714https://scdhec.gov/covid19/covid-19-vaccine
      South DakotaYes (1d)Yes884,659https://doh.sd.gov/documents/COVID19/Vaccine/COVIDVaccineAvailability_Distribution.pdf
      TennesseeYes (1c)No6,829,174https://covid19.tn.gov/covid-19-vaccines/vaccine-phases/#1c
      TexasYes (1b)Yes28,995,881https://www.dshs.texas.gov/coronavirus/immunize/vaccine.aspx#eligible
      UtahNoNo3,205,958https://coronavirus.utah.gov/vaccine-distribution/#eligibility
      VermontYes (5A)No623,989https://www.healthvermont.gov/covid-19/vaccine/about-covid-19-vaccines-vermont#conditions
      VirginiaYes (1b)Yes8,535,519https://www.vdh.virginia.gov/covid-19-vaccine/#phase1b
      WashingtonYes (1b)No7,614,893https://www.doh.wa.gov/Emergencies/COVID19/VaccineInformation/AllocationandPrioritization
      Washington D.C.Yes (1c)Yes705,749https://coronavirus.dc.gov/vaccine
      West VirginiaYes (2a)Yes1,792,147https://dhhr.wv.gov/COVID-19/Pages/Vaccine.aspx#timeline
      WisconsinNoNo5,822,434https://www.dhs.wisconsin.gov/covid-19/vaccine-about.htm
      WyomingYes (1b)Yes578,759https://health.wyo.gov/publichealth/immunization/wyoming-covid-19-vaccine-information/
      Results of the review of state prioritization planning for pregnant individuals. Data were collected on March 6, 2021, and may not represent recent changes in planning or eligibility.
      COVID-19, coronavirus disease 2019.
      Crane. Prioritization of pregnant individuals in state plans for coronavirus disease 2019 vaccination. Am J Obstet Gynecol 2021.
      a Phase listed refers to the first phase or subphase in which pregnant individuals are prioritized for vaccination. These have been rounded to the nearest subphase when divided into subphase tiers. States which do not follow a clear, phased approach to vaccination but still prioritize pregnant individuals are listed only as “Yes.” When pregnant individuals are prioritized across multiple phases, they are listed here under the earliest phase in which they are enumerated
      b Eligibility varies in some states at the county level. Results here refer to eligibility of pregnant individuals in at least some counties within a state, even if there are additional requirements such as multiple, high-risk health states or an age threshold. States were not enumerated if they rely on reference from a physician to determine vulnerability to COVID-19 without specific mention of pregnancy
      c Population counts obtained from 2019 US Census Bureau Data (https://www.census.gov/newsroom/press-kits/2019/national-state-estimates.html)
      d At the time of plan analysis, Arizona was transitioning toward an age-based approach to COVID-19 vaccine eligibility and not all government resources had been updated to reflect this policy adjustment. Our analysis reflects the anticipated age-based approach.

      Conclusion

      Most states classify pregnant individuals as a priority group for initial COVID-19 vaccinations, and in almost 50% of the states, they are currently eligible to receive vaccines. These results differ substantially from previous findings published in early February 2021, which found that 15 of the 51 jurisdictions had prioritized pregnant individuals.
      • Grünebaum A.
      • McCullough L.B.
      • Litvak A.
      • Chervenak F.A.
      Inclusion of pregnant individuals among priority populations for coronavirus disease 2019 vaccination for all 50 States in the United States.
      The increased prioritization of pregnant people for COVID-19 vaccination marks important progress—it is both ethically imperative and supported by recommendations from professional US obstetrics societies and the CDC.
      The American College of Obstetricians and Gynecologists
      Vaccinating pregnant and lactating patients against COVID-19. 2020.
      ,
      Centers for Disease Control and Prevention
      Interim clinical considerations for use of COVID-19 vaccines currently authorized in the United States. 2021.
      Continued efforts to ensure equitable access to COVID-19 vaccines for pregnant people require, at minimum, that all states prioritize pregnancy as equal with the CDC-listed, high-risk health conditions based on the available, objective data.
      Even where pregnant people are eligible for COVID-19 vaccinations, personal decision making is complicated by the overall lack of pregnancy-specific safety data. Vaccine studies among pregnant people are underway and early registry data are reassuring. To date, pregnancy outcomes among nearly 2000 vaccinated pregnant people are no different from those in the general population, suggesting that the messenger RNA vaccines have no adverse effects on pregnancy.
      Centers for Disease Control and Prevention
      v-safe COVID-19 vaccine pregnancy registry. 2021.
      Pregnant people deserve the clearest possible guidance from public health agencies about their eligibility for COVID-19 vaccinations and whether the likely benefits of vaccination during pregnancy outweigh the risks.

      References

        • Dooling K.
        • Marin M.
        • Wallace M.
        • et al.
        The Advisory Committee on Immunization Practices’ updated interim recommendation for allocation of COVID-19 vaccine—United States, December 2020.
        MMWR Morb Mortal Wkly Rep. 2021; 69: 1657-1660
        • Grünebaum A.
        • McCullough L.B.
        • Litvak A.
        • Chervenak F.A.
        Inclusion of pregnant individuals among priority populations for coronavirus disease 2019 vaccination for all 50 States in the United States.
        Am J Obstet Gynecol. 2021; 224: 536-539
        • The American College of Obstetricians and Gynecologists
        Vaccinating pregnant and lactating patients against COVID-19. 2020.
        (Available at:)
        • Centers for Disease Control and Prevention
        Interim clinical considerations for use of COVID-19 vaccines currently authorized in the United States. 2021.
        (Available at:)
        • Centers for Disease Control and Prevention
        v-safe COVID-19 vaccine pregnancy registry. 2021.
        (Available at:)