As scientists worldwide sprint to develop a COVID-19 vaccine in record time, local doctors and public health officials are planning another race with enormous implications: quickly distributing doses to – and injected into – Maine’s dispersed population.

Vaccinating for COVID-19 is expected to be the largest mass-immunization campaign in history. But success or failure depends both on the effectiveness of the vaccine and convincing enough people to get inoculated to achieve “herd immunity.”

That will require an extensive public education campaign about the safety and necessity of the vaccine but also to overcome concerns, among some, that the Trump White House pressured researchers to rush a vaccine during an election year.

In Maine, the vaccination push could be complicated by the state’s spotty access to health care and a population segment already skeptical of decades-old vaccines, never mind one produced by “Operation Warp Speed.”

“The greatest challenge across the U.S. is making sure our communities know the vaccine is safe, has been fully tested and has good efficacy,” said Kathy Knight, director of the Center for Emergency Preparedness at Brewer-based Northern Light Health. “There are a lot of folks out there who are concerned because, on the news, there is a lot of information about the process having moved more rapidly than normal.”

The speed at which a COVID-19 vaccine is being developed is, in fact, unprecedented.

Researchers around the world are working on 150 potential COVID-19 vaccines, with more than two dozen already at the human-trials stage.

While a fall vaccine appears unlikely, despite recent statements by President Trump, the federal government is already paying manufacturers to mass-produce several promising vaccines in order to jumpstart distribution should they prove safe during clinical trials.

“We likely are going to have maybe tens of millions of doses in the early part of the year but, as we get into 2021, the manufacturers tell us that they will have hundreds of millions and likely a billion doses by the end of 2021,” Dr. Anthony Fauci, the nation’s top infectious disease expert, told Reuters last week.

But creating an effective vaccine is only part of the equation.

“It’s going to change everything and we have to be ready months before the vaccine is approved,” said Dr. Nirav Shah, director of the Maine Center for Disease Control and Prevention, who has been been helping to lead the monthslong vaccine planning process in Maine. “We have to be ready, internally and externally.”

PLANS BASED ON ‘GOOD SCIENCE’

Such logistical discussions have, understandably, not drawn as much attention as the breakneck pace of the global efforts to develop, test and mass-produce a COVID-19 vaccine. But those behind-the-scenes planning sessions – taking place in conference rooms, Zoom meetings and webinars across the country – are critical to the success of a vaccine rollout.

The National Governors Association released a nine-page memorandum last week detailing steps the chief executives in every state should consider, from arranging for cold storage of mass quantities of perishable vaccines to getting a head start on vaccine messaging.

“Recent polling shows only half of Americans plan on getting the COVID-19 vaccine once it is made available,” reads the NGA memo. “With vaccine coverage an essential part of population protection, governors may want to begin communicating about vaccination now.”

Maine Gov. Janet Mills’ Coronavirus Response Team has been working with state and local health authorities “to evaluate and address barriers that could prevent Maine people from being vaccinated and to strengthen existing infrastructures,” said spokeswoman Lindsay Crete. Part of that plan will build on the distribution system for personal protective equipment already operating during the coronavirus pandemic.

“She agrees with concerns raised in the NGA memo about adequate warehousing, distribution systems, population priority and the availability of syringes, tubes and other supplies in the volumes necessary, as well as adequate supplies of the vaccine itself,” Crete said in a statement. “Decisions must be made on the basis of public health and good science, pure and simple. Politics should have no role in such decisions.”

At Northern Light Health, officials are discussing utilizing the system’s nine COVID-19 testing locations — most of which offer drive-up testing — at hospitals scattered across Maine. Additionally, Knight said Northern Light is exploring potential mass-vaccination clinics at Bangor’s Cross Insurance Center or other arenas, which has been done before for the flu vaccine and the H1N1 vaccine in 2009.

“We are looking at multiple strategies because when it comes to COVID, we don’t know what that is going to look like,” said Knight.

Shah said Maine CDC will likely rely on the Maine National Guard and the state Department of Transportation for deliveries, building on the a now well-oiled distribution system for PPE and testing equipment launched in the early days of the pandemic.

WHO GETS PRIORITY?

Other questions are more vexing.

Who should be allowed to give the shots? Does Maine have enough nurses? And how about syringes? Could the vaccine be administered at drive-through locations?

And perhaps most controversially – who should get first priority for a vaccine given that supplies will likely be limited, at least at first?

“I’m more concerned about the ethical decisions about who has access to the early vaccines,” said Devon Greyson, an assistant professor at the University of Massachusetts-Amherst who has studied vaccine policy and public perception. “There are going to be some challenging decisions that we would rather not get politicized around distributing the vaccine. …  I anticipate there will be a lot of press coverage and more demand (than supply).”

Maine has, to date, avoided the doomsday scenarios that appeared possible in mid-March as doctors in Italy and other countries were forced to decide which critically ill COVID patients should receive life-sustaining care and which should not.

With roughly 4,000 cases to date among a population of 1.3 million, Maine has the third-lowest infection rate in the country after Hawaii and Vermont, according to tracking by The New York Times. Maine accounts for just 125 of the more than 158,000 deaths reported nationwide among individuals with COVID-19.

But recent outbreaks in other rural states underscore the ever-present risks here, particularly as visitors from harder-hit areas choose to vacation in Maine.

‘WE HAVE TO BE VERY CAREFUL’

And then there is the potential issue of “vaccine hesitancy” in Maine, particularly when dealing with a virus that has been politicized across the country.

Public polling has repeatedly captured the discomfort with – even distrust in – a vaccine developed at record speed.

“We have to be very careful,” said Dr. Laura Blaisdell, a Yarmouth pediatrician who helped lead the ballot box defense of Maine’s new law eliminating religious and philosophical exemptions for childhood vaccinations. “Our vaccine confidence in the U.S. is fragile, … and in Maine, as we’ve seen with the referendum.”

In May, just 49 percent of respondents to one national poll said they planned to get a COVID-19 vaccine while 31 percent were undecided and 20 percent said they would not get vaccinated. Those numbers have improved somewhat as coronavirus infections and deaths continue to climb, however.

In a nationwide survey of more than 19,000 adults in July, 66 percent of respondents said they were in “somewhat likely” or “extremely likely” to vaccinate themselves once a vaccine becomes available. That figure was 69 percent among the 314 Maine residents who participated in the poll, conducted by researchers at Harvard, Rutgers, Northeastern and Northwestern universities.

Those figures are below the 70 percent vaccination rate believed necessary to hit “herd immunity,” which is the threshold at which enough of the population has been immunized to reduce the likelihood of an infectious disease spreading.

Nor is “vaccine hesitancy” a uniquely American problem. In a recent survey, nearly one in six respondents in the United Kingdom said they would refuse a COVID-19 vaccine. In another poll of European residents, 30 percent of German respondents and 38 percent of participants in France were either unsure or opposed to a vaccine.

Maine CDC officials said last week that the agency is still developing plans for vaccine distribution and any public awareness campaign as well as the additional money that will be required for both. In an interview, Shah said one option is tapping individuals in Maine “who are universally respected to help instill that vaccine confidence.”

CONCERNING TRENDS IN MAINE

Yet Maine also has lower-than-average vaccination rates and recently endured a fierce, several-year debate over mandatory childhood immunizations.

Maine had among the nation’s lowest rates of childhood vaccinations in 2018-19 due, in large part, to parents citing exemptions to the state law requiring that children receive a suite of inoculations before entering school. In 2018, Maine had the highest rate of pertussis, or whooping cough, in the country.

Those statistics, combined with unvaccination rates topping 30 or 40 percent in some elementary schools, raised fears about Maine losing the “herd immunity” that protects children who cannot be immunized for medical reasons. Public health advocates responded by successfully pushing a bill through the Legislature to eliminate religious and philosophical exemptions for children attending schools.

But the fierce debate didn’t end there as opponents put the issue to a statewide vote, arguing that mandatory vaccinations violated parental and religious rights. Maine voters resoundingly rejected the “people’s veto” measure that appeared as Question 1 on last March’s ballot, ending the political debate but not the distrust some harbor.

The push to quickly develop a COVID-19 vaccine, compounded with Trump’s repeated questioning of his own scientific experts on the virus, has stoked fears among vaccine skeptics and Trump critics nationwide.

“Will do whatever it takes to protect my family from this ridiculously rushed vaccine,” wrote one commenter on a March story on the risks of accelerated safety testing that was posted on the Facebook page of the “Yes on 1” campaign.

Greyson, the UMass professor who has studied “vaccine hesitancy” trends internationally, cautioned against allowing the discussion over COVID-19 vaccines to veer into debate over vaccine mandates. There will likely be more demand than supply for any vaccine, so talk of mandates at this point is pointless and “just makes people upset.”

Instead, Greyson said public health officials should reach out now to leaders in communities with lower vaccination rates – whether because of access to health care, religious or other reasons – to start laying those groundwork conversations about a future COVID-19 vaccine.

“It’s hard to build confidence in any population when we don’t know the details of any vaccine,” Greyson said. “We can’t say ‘Trust us’ when we don’t have the data, … but what we can do is generally build trust within hesitant communities.”

‘ZERO PERCENT HERD IMMUNITY’

Even the way public health officials like Shah or researchers talk about vaccinations has changed. They use phrases like “vaccine hesitancy” and “vaccine confidence,” steering clear of more pejorative descriptors such as “anti-vaxxers.”

Shah said the country is in the midst of what, for many, is one of the most frightening periods in recent history. And the prospect of a fast-tracked vaccine is disconcerting for many, particularly coming on the heels of Maine’s political fight over vaccination mandates for schoolchildren.

So Shah said he has “been spending a lot of time thinking about how we make the case for efficacy of vaccination” in ways that will make Maine residents feel confident enough to actively want the vaccine.

“For way too long, for literally a generation or two, science and public health experts have looked upon the question of vaccines with something that I call scientific paternalism – we know better than you and we are going to tell you what to do,” Shah said. “And that is not the way to get buy-in.”

Instead, Shah said, he and other public health officials need to “approach skeptics with compassion and understanding.” And he urged people to listen to the reasons why others hold strong beliefs and recommended seeking out credible information sources, such as the World Health Organization or the CDC.

“When we move beyond what people believe and start talking about why people believe the things they do, I think that’s where productive dialogue starts, whether it’s about COVID-19 generally or vaccinations in particular,” Shah said.

Blaisdell, the Yarmouth pediatrician who has researched vaccine hesitancy, worries that the COVID-19 vaccination issue will become more politicized as the November election approaches. She said the Phase 3 drug trials now underway with human patients cannot be rushed, and that additional scientific advisory committees should be brought in to “build scientific consensus” around the safety of any vaccine.

“While time is not on our side in this global pandemic and we need to get to a place of herd immunity, … I think it behooves us to be very careful in these final trials,” Blaisdell said.

Vaccination advocates should also steer well clear of any talk of mandates in the case of COVID-19, she said. Despite lingering skepticism among some, vaccines for measles, mumps, polio and chickenpox were proven safe over decades before they were mandated for children attending school.

But Blaisdell thinks – or hopes – that most Mainers will want to get vaccinated for COVID-19.

Nowadays, she added, widespread vaccination and the resulting herd immunity means most Americans are protected from such debilitating diseases as measles or polio – so much so that it’s no longer even a thought. But with COVID-19, she said, “we are at 0 percent herd immunity, or very little.”

“When the risk is higher of contracting a disease, people make different vaccine decisions, … and I think it is different with COVID because we feel we are all at risk,” Blaisdell said.