Exactly who will be inoculated first against the ravages of COVID-19 remains unclear as Maine prepares to launch a statewide vaccination effort within days.

Federal and state health agencies have issued broad guidelines saying the first doses of the Pfizer vaccine that was approved Friday should be offered to front-line health care workers and residents of long-term care facilities, both groups that have been hit hard by the pandemic.

But the U.S. Centers for Disease Control and Prevention has yet to issue detailed guidelines on who should be given priority within those groups, a void that has left hospital and long-term care administrators to decide which employees, patients or residents will be protected first.

Those complex decisions being made across Maine are just the start of ethical and political challenges presented by the historic COVID-19 vaccination rollout. Hospitals and long-term care facilities have already begun sharing inoculation plans with staff members and patients, and asking about their willingness to be vaccinated.

The process of determining who should be inoculated first could grow more tangled in the months ahead as additional vaccines become available to more groups and, eventually, the general public. Should 80-year-olds be vaccinated before 60-years-olds? What about people with underlying health problems, racial minorities, low-income Mainers and other underserved populations?

“There are no easy answers. There are only unsavory choices to make,” said Dr. Nirav Shah, director of the Maine Center for Disease Control and Prevention. “That is the unfortunately harsh reality of doing this kind of work in the midst of a pandemic.”

As the Maine CDC and other agencies try to plan the distribution of the first vaccine doses, they’re working from general recommendations and interim “considerations” issued by the U.S. CDC’s Advisory Committee on Immunization Practices in early December.

Shah said he has asked hospitals and long-term care facilities to prioritize the first allocations of vaccines for people who are at highest risk of contracting the virus. He suggested that a nurse who works in a COVID unit eight hours a day should be inoculated before a food service worker who delivers meals to COVID patients one hour a day. But current state and federal guidelines for administering COVID-19 vaccines offer no such examples.

When the Portland Press Herald/Maine Sunday Telegram asked the Maine CDC for detailed prioritization guidelines issued by either state or federal authorities, it referred to general federal recommendations including, “Jurisdictions might consider first offering vaccine to health care personnel whose duties require proximity (within 6 feet) to other persons,” which likely would include every health care worker.

MaineHealth, a health care group with more than 22,000 employees across the state, plans to first vaccinate workers in intensive care units, emergency departments and dedicated COVID-19 units in its primary COVID care hubs: Maine Medical Center in Portland, Southern Maine Health Care in Biddeford and Mid Coast Hospital in Brunswick.

MaineHealth administrators based their initial priority list on a broad federal suggestion that “early protection of health care personnel is critical to preserve capacity to care for patients with COVID-19 or other illnesses,” said Dr. Joan Boomsma, MaineHealth’s chief medical officer.

Boomsma said the group is focusing first on direct-care providers in ICUs, ERs and COVID units because infection and hospitalization rates continue to spike across Maine and the nation. Vaccination clinics for MaineHealth personnel could start this week, she said.

“We want those people to be protected from community spread … so we can continue to have healthy care teams in our hospitals,” Boomsma said. “We need ICU beds, and the surge of COVID-19 is starting to strain our system.”

The number of COVID-19 patients admitted at Maine Med hit 40 last Thursday and averaged 36 per day for the week ending that day, up from 25 the week before, according to data from the Maine Department of Health and Human Services. The previous single-day peak was 35, on both April 7 and May 25.

In the week ending Dec. 7, Maine Med’s ICU had a nightly average of 92 patients among 115  beds. On average, 16 of those patients had COVID-19, the same number of COVID-19 patients that were in the ICU on Friday.

MaineHealth has formed a systemwide task force to schedule inoculation clinics and oversee vaccine distribution among front-line care teams as soon as doses become available, Boomsma said.

MaineHealth is set to receive an initial allotment of nearly 1,900 doses of the Pfizer vaccine this week. With the anticipated approval of the Moderna vaccine as early as this week, MaineHealth expects to get an additional 15,775 doses the week of Dec. 20.

The Maine CDC expects to receive 74,875 vaccine doses overall in the first three weeks of the rollout, including the Moderna vaccine. The state has an estimated 75,000 health care workers with direct patient contact and about 6,000 residents of nursing facilities.

Both vaccines require a second dose – Pfizer’s within 21 days and Moderna’s within 28 days – although some experts say the date of the booster doesn’t have to be so precise. Federal officials have said they plan to hold an equal number of second doses in reserve to complete the inoculation of the first 74,875 people.

Maine officials are skeptical of the plan to withhold second doses because COVID-19 vaccine development has been plagued by ever-changing federal projections, politically charged promises, and production and distribution problems that originate far beyond Maine’s borders.

“The proof is in the pudding, right?” said Shah, the Maine CDC director.

Without detailed guidance from the federal government, no two states have prioritized their vaccination populations in exactly the same way, according to an analysis by the National Academy for State Health Policy.

Most state vaccination plans are “informed” by basic federal guidelines, while some plans are “enhanced” by community sources, the academy found. The federal Advisory Committee on Immunization Practices was expected to issue additional prioritization recommendations after the FDA approved a vaccine, possibly this week.

But if vaccine distribution begins 24 hours after FDA approval, as federal officials have planned, the academy predicted that many states could get the vaccine before the advisory committee issues recommendations.

“While the vaccine will ultimately be available to everyone, states must make important policy decisions to ensure timely, ethical, and equitable distribution of the vaccine during initial phases when supply is limited,” the academy warned last week.

Shah defended some of the detail that’s lacking in Maine’s vaccination plan, especially the projected total numbers of vaccine doses Maine will receive and people who will be inoculated in each phase of the rollout.

“There is a bit of false specificity that can occur in situations like this,” Shah said. “The numbers don’t inform (if) they are outdated the minute they are published. Our allocations of doses are changing minute by minute. I would rather say to folks, based on what I know right now, we are getting 12,675 doses, and that is likely to change.”

Broad federal guidelines for COVID-19 vaccination define health care personnel as “all paid and unpaid persons serving in healthcare settings who have the potential for direct or indirect exposure to patients or infectious materials.” They also say health care workers and long-term care residents should be vaccinated early to “maximize benefits, minimize harms, promote justice and mitigate health inequities.”

They note that there are about 21 million health care workers in hospitals, long-term care facilities, clinics, home health agencies, emergency medical services and pharmacies across the United States, including doctors, nurses, food service workers, administrator and facilities crews.

They also note that, nationwide, about 245,000 COVID-19 cases and 858 COVID-19-associated deaths had been reported among health care personnel as of Dec. 1; and about 500,000 COVID-19 cases and 70,000 associated deaths had been reported among residents of skilled nursing facilities as of Nov. 15.

They suggest “further considerations around use of COVID-19 vaccines” for pregnant or breastfeeding women will be coming once testing among those groups has been done, largely because 75 percent of health care personnel are women, according to the Association of State and Territorial Health Officials.

They also suggest “sub-prioritization” among long-term care facilities, which would focus first on skilled nursing homes with the most medically vulnerable residents, then “consider broadening” to assisted-living facilities, state veterans homes and other congregate care homes.

And because inoculation can trigger fever, headaches and muscle pain, federal guidelines also suggest staggering vaccine delivery within departments and across facilities to avoid widespread personnel shortages that could happen if many staff members call in sick on the same day.

It’s something Maine Med and other facilities are planning to do, from ICU staffs to maintenance crews, because they’re already experiencing staffing shortages related to surging infection rates.

“You can’t just go in and blast everybody with the vaccine, because we know from the clinical trials that a fraction of people will get symptoms,” Shah said. “You’ve got to think this stuff through.”

But as hospitals and long-term care administrators juggle scheduling and logistical concerns, ensuring equity in the COVID-19 vaccine rollout is viewed as a primary aspect of building community trust and promoting public buy-in. Maine’s congressional delegation is pressing for more information about the vaccination program to be posted publicly so people can be sure there’s equal access across states.

It’s a long-haul proposition that likely will see some Mainers getting inoculated against COVID-19 in the last half of 2021 and require mask wearing and social distancing into 2022. Hospital officials across Maine are taking steps to encourage vaccination among their employees and in their communities.

“This is an unprecedented experience for all of us,” said MaineHealth’s Boomsma. “But in many ways we’ve been preparing for this for a long time, so we’re doing our best.”

Prior to the pandemic, Maine’s inoculation rates had been on the rise for several years. The proportion of adult Mainers who had age-appropriate vaccinations increased from 37 percent in 2012 to 44 percent in 2019, surpassing the national average of 40 percent, according to The Commonwealth Fund’s Health System Data Center.

As head of the Maine CDC, Shah said he hopes to instill confidence in the product and the process, by being transparent and accountable to both supporters and skeptics of vaccination. He’s especially concerned about promoting vaccination in future phases among marginalized groups that have been greatly impacted by the pandemic, especially people of color.

“There is no question that certain groups have borne a disproportionate and unacceptable share of the (COVID-19) cases,” Shah said. “One of the reasons I feel strongly about casting a net for essential workers is that many are simultaneously members of marginalized groups.”

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