When the trucks roll into Maine with the first batches of COVID-19 vaccine doses – perhaps as soon as mid-December – the state will need to overcome many logistical hurdles to bring the vaccines to pharmacies, doctors’ offices, hospitals, schools, fire halls and eventually the arms of patients.

The mass vaccination effort will be a daunting operation, and planning for it has been underway for months. The pandemic has accelerated this fall, so getting people vaccinated as quickly as possible is a top priority for public health officials. Since the pandemic began last winter, more than 255,000 people have died in the United States from COVID-19, including 174 in Maine.

The effort will likely involve the National Guard, firefighters, paramedics, the Maine Department of Transportation and an army of health care workers, to get the vaccine to as many people as possible as quickly as possible, said Dr. Nirav Shah, director of the Maine Center for Disease Control and Prevention.

Two vaccines are in the final stages of testing and review before the U.S. Food and Drug Administration will consider them for approval. One is being developed by Pfizer and the other by Moderna, and both use similar technology to attack the virus.

The details of how exactly the vaccines will be given to patients at pharmacies and mass immunization clinics – such as how patients would sign up – are still being worked out, said Robert Long, Maine CDC spokesman.

“We know it will be done in an orderly way,” Long said. “We know the broad terms of the distribution, but we still need more information from the federal government, Pfizer and Moderna to finish the planning.”

The Pfizer vaccine will require ultra-cold storage of minus 70 degrees Celsius, and Shah said the Maine CDC will get two freezers in early December and that a deal is being finalized with the University of New England to loan a “gargantuan” ultra-cold freezer. The Moderna vaccine will not need ultra-cold storage.

The FDA could grant emergency use authorization for both vaccines as early as Dec. 10, followed within days by initial distribution to states. The pharmaceutical companies have said they have the ability to deliver 20 million doses of each vaccine by the end of 2020, with hundreds of millions or perhaps billions of doses rolled out in 2021.

HEALTH CARE WORKERS FIRST

It’s difficult to predict when most people will be able to get immunized. Some experts say it could happen as early as April, and others say it would be more next summer or early fall.

Among the first in line will be health care workers and nursing home residents.

An online tool published by Harvard University estimates that the first batch of doses Maine would receive would vaccinate 40,000 Mainers, about half of the health care workforce in the state.

Dr. Dora Anne Mills, chief health improvement officer at MaineHealth, which operates a network of hospitals and health care services including Maine Medical Center, said plans to have the network’s 23,000 employees vaccinated have been in the works since August, with the first vaccines going to intensive care and emergency room employees.

“We are going to be converting hospital conference centers into vaccination sites,” she said. “This effort is going to be all hands on deck.”

Next will be people 65 and older, school employees, prison workers and those with underlying health conditions.

When the state is ready to vaccinate seniors, Shah said, everyone 65 and over will be able to get vaccinated. Even though a healthy 65-year-old is less vulnerable than a 90-year-old with underlying conditions, making distinctions like that would slow the vaccination process too much.

The third phase will include children, young adults and people who work in high-risk industries or essential jobs. In the final phase, all Mainers would be eligible.

Assuming vaccine supplies are plentiful, Maine will be able to vaccinate 80 percent of its 1.3 million residents within 12 weeks, according to the state plan submitted to the federal government in October.

The doses will be parceled out to states on a per capita formula, according to the federal CDC. Some doses will go to state health offices, while others may go straight to pharmacies and health care systems.

But will states be ready?

“We are talking about huge distribution networks that will be needed, plus information systems, staffing,” said Jen Kates, senior vice president of global health and HIV policy at the Kaiser Family Foundation, a national health policy think tank. “All of these things will go into the biggest mass vaccination program in history.”

The Kaiser Family Foundation has evaluated all 50 state plans submitted to the federal government on vaccine distribution, and Kates said Maine’s is among the best.

“Maine’s plan is quite good, very thorough, and they very clearly have comprehensive plans in place on how to distribute the vaccine,” Kates said. Most state plans don’t go into as much detail as Maine’s on how the vaccines will be rolled out, she said.

WHERE WILL THE VACCINES BE?

Once significant doses of the vaccine become available, expect it to be in many places – not only pharmacies but school parking lots, fire departments, social clubs, hospitals, health clinics, Shah said in an interview. The goal is “velocity and equity,” he said, to make sure that minority populations and rural areas have access.

The goal is to distribute the vaccine to all parts of the state when the doses come in, so rural areas will get the vaccine around the same time as cities, Shah said.

“We are going to take an ‘all approaches on the table’ strategy,'” Shah said. “We want to bring the vaccine as close to people as possible. We are creating large-scale infrastructure, large-scale clinics that can handle a lot of traffic. We don’t want 200 people packed into a Walgreens in the middle of February waiting for their shot while the pandemic is still going on.”

That said, pharmacies will be a key part of the vaccine rollout, and the state is partnering with the Maine Pharmacy Association to make it convenient for people to get COVID-19 vaccines at their corner drugstore.

Kenneth McCall, professor of pharmacy at the University of New England and past president of the Maine Pharmacy Association, said the scale of the rollout will be of several times greater magnitude than the annual flu shot. By the time vaccines are widely available, he said, people will be able to walk into their local pharmacy and get a COVID-19 shot, the same way they get flu shots.

Unlike flu shots, though, both the Moderna and Pfizer vaccines require two doses weeks apart. But by next spring, other vaccines that require only a single dose may be approved.

Getting to that point will be difficult, McCall said, because of the daunting logistical challenges, some of which are outside the state’s control.

“This will be an extraordinary effort,” McCall said. “But we have never invested this many resources at one problem.”

Pharmacies are already hiring more pharmacists, some on a contract basis, and pharmacy interns in preparation for mass vaccination, McCall said.

How exactly pharmacies will take appointments for COVID-19 flu shots is not yet known and depends on supply, but McCall said if the rollout goes well it should be as simple as getting a flu shot.

To head off any problems with staffing, other people will be trained to vaccinate, including firefighters and paramedics, and possibly members of the National Guard, Shah said. The state is hiring more public health nurses, who will be a key component of vaccination clinics, he said. School nurses will also likely be enlisted to help, Shah said.

While more than 90 percent of Mainers live within a 30-minute drive of a pharmacy, some towns have only one pharmacy, so planners are working to make sure there’s enough physical space for vaccination clinics. They are lining up alternative locations, such as fire halls, social clubs and schools. There could be heated tents in parking lots.

Some or all of the 27 “swab-and-send” sites set up by the Maine Department of Health and Human Services for COVID-19 testing in the coming months will likely become vaccination sites, Shah said.

The swab-and-send sites are mostly health care locations, such as hospitals and clinics, but also include the Westbrook Public Safety building, Portland International Jetport and the Auburn Transportation Center.

Regardless of state planning, Kates said, the public could still experience periodic bottlenecks and vaccine shortages.

“Is there going to be enough supply to match up with what is needed?” she said. “We could have situations where people who want the vaccine can’t get it, just like there have been periodically shortages of the flu vaccine or the shingles vaccine.”

OTHER LOGISTICAL PROBLEMS

One looming problem is the outgoing Trump administration’s refusal to work with President-elect Joe Biden’s transition team, including on vaccine distribution, Kates said. Without a smooth handoff, logistical problems with vaccine rollout could worsen when the Biden administration takes over Jan. 20.

“This is not going to be a problem just for President-elect Biden’s transition team,” Kates said. “This could be a problem for everyone in the country.”

Another issue, Kates said, is the lack of federal funding to help states distribute the vaccine, with an estimated $6 billion to $8 billion needed. COVID-19 aid packages, which would include the vaccine distribution funding, are stalled in Congress.

Shah said federal funding is needed, but it’s not clear how much would be required for Maine because it depends on which vaccines are most widely distributed to the states. If it’s mostly the Pfizer vaccine, which requires ultra-cold storage, that will be more expensive than the other vaccines.

States could still get the job of distribution done, Shah said, but it would go much faster with a boost in federal funding.

The Moderna vaccine would give the state more flexibility. It can be stored in a regular freezer or even a refrigerator for up to 30 days, which will make it easier to distribute to far-flung areas.

The Moderna vaccine also comes in batches of 100, compared to 975 per batch of Pfizer doses, so the Moderna vaccine will more likely go to areas where fewer people live, Shah said.

Other challenges include creating databases and record-keeping to ensure that people return for second doses.

Another hurdle is a full-press communication effort to convince people that the vaccines are safe, Kates said. There has been concern about people’s willingness to get vaccinated, Kates said, but the severity of the pandemic and the effectiveness of the Pfizer and Moderna vaccines – as high as 95 percent – may ease people’s fears. (The annual flu vaccine, by contrast, fluctuates between 40 percent and 60 percent effectiveness.)

Pharmacists will be critical in helping people see the safety of the vaccines, McCall said.

“There will be a point very soon where the local pharmacist is going to be able to answer a lot of the questions people will have about the vaccine,” McCall said. “I think we can make a big difference on the ground level.”

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