Objectives: When vaccine supply was limited, several states adopted age-based prioritization for Covid-19 vaccine eligibility because it is simple (especially when age is quantized by decade) and age is strongly associated with Covid-19 mortality. But this approach raises equity concerns based in law and ethics. I propose data-driven solutions for equitable policy within an age-based framework. Methods: Using CDC and Census Bureau data, I analyzed 538,627 U.S. Covid-19 deaths by age and race-ethnicity through February 2021 and compared the risk ratios to published data on risk ratios for other conditions. Results: Covid-19 mortality rose 2.56-fold per decade of life. Down syndrome, organ transplantation, and intellectual/developmental disability all have higher risk ratios. Conclusions: People with specific conditions associated with a risk ratio of 2.56 or 6.54 should become vaccine-eligible along with people 10 or 20 years older, respectively. Even as vaccines become more available, data collection and reporting through disability systems should be integrated with general public health systems, including vaccination databases, in order to assess Covid-19 mortality associated with intellectual or developmental disability per se and to make it possible to track vaccine progress in this marginalized population. People from these groups should also be involved in decision making and advisory bodies.

Plain Language Summary

Old people are more likely than younger people to die from covid-19. Some states have let older people get vaccines before younger people, even if the younger people had disabilities. These states gave 70-year-olds vaccine access, then 60-year-olds vaccine access, and so on. So how much does risk of covid-19 death go up when people age 10 years? When you are 10 years older, your risk of dying from covid-19 is 2.6 times higher. People with severe kidney disease and people with intellectual or developmental disabilities who live in group homes are also about 2.6 times as likely to die from covid-19. People with Down syndrome, people with with intellectual or developmental disabilities living in ICFs, and people with organ transplants are even more likely to die from covid-19. If a state or country lets old people get vaccines early then they should let people with organ transplant or severe kidney disease get vaccines with people 10 older. They should let people with intellectual or developmental disabilities in group homes or ICFs get vaccines with people 10 or 20 years older. They should let people with Down syndrome get vaccines with people who are much older. States and countries should also include disability when they report data on covid-19. This should include vaccination data. They should not segregate data about disability. People from marginalized groups should be included in decision making, and decisions should change with new information.

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