Seven weeks into the largest mass-vaccination effort in the nation’s history, Maine is performing better than most states in getting shots into arms amid a severe, worldwide supply shortage of COVID-19 doses.

But Maine’s vaccination program has also been beset by a host of problems – many national in scope and cause, others with local roots – that have delayed inoculations for some of the state’s most vulnerable residents and sowed confusion among others.

With the pace of vaccinations quickening, more than 8 percent of Maine residents had received at least one dose as of this weekend, which is slightly higher than the national average. The state continues to face multiple challenges, however, including:

• Roughly 30,000 of the 108,519 first doses administered as of Saturday had been given to Mainers age 70 or older, who are now the state’s top priority. Although that figure is growing daily, with record vaccination numbers reported Friday, it would take eight more weeks to inoculate all 190,000 people in that age group at current vaccine supply rates.

• For three consecutive weeks, state officials have diverted thousands of vaccine doses from Walgreens and CVS to independent pharmacies because the retail chains have been too slow to vaccinate residents of long-term care facilities.

• The lack of a statewide registration system has left many older Mainers confused and frustrated as they attempt to get “on the list” and secure an appointment.

“The question is: what do I do?” said Dennis Buckley, 77, who was able to register along with his wife two weeks ago but has yet to get an appointment date. “That has been the question since the vaccine came on line and that’s still the question: what do I do to make sure we don’t fall through the cracks? And I don’t know.”

The York couple, like thousands of other older Mainers across the state and nation, are left waiting for that much-anticipated call.

“We absolutely understand the fact that Maine is not getting enough vaccines,” said Marie Buckley, 76. “They can’t give out what they don’t have.”

Looking ahead, Maine also faces the enormous logistical hurdles of getting vaccine doses into rural communities where access to health care is a perennial issue.

“That will be the challenge going forward,” said John Gale, a senior research associate at the University of Southern Maine’s Cutler Institute and the Maine Rural Health Research Center. “We are treating it like a medical issue rather than a public health issue, … so how do we move from a medical response, in a clinic or hospital, to a broader response where we vaccinate larger numbers of people” in rural areas?

PERCENTAGE SLOWLY CLIMBING

Maine is wrapping up the first phase of vaccinations – focused largely on health care professionals, public safety employees and nursing homes – and has begun vaccinations of residents age 70 or older. Next on the list are individuals with high-risk medical conditions, Mainers between the ages of 65 and 69 and, eventually, an as-yet-unidentified segment of essential front-line workers.

So far, Maine is doing better than most states.

As of Saturday, 7.6 percent of Maine’s population had received the first dose of either the Pfizer or Moderna vaccines while 2.6 percent had received both required doses, according to tracking by Bloomberg News. Those are the 10th and fifth highest rates, respectively, among the states. The national average for first doses was 6.8 percent while 1.4 percent nationally have been fully inoculated. (The percentages reported by the Maine Center for Disease Control and Prevention for the state were slightly higher than those used by Bloomberg.)

“What’s working, I believe, in terms of the state of Maine is that people have tackled this with a rational mindset and have prioritized the right population, prioritized getting the vaccine out as quickly as possible and chosen the mechanisms to do that,” said Dr. Stephen Shannon, a retired physician from Biddeford who serves as president emeritus of the American Association of Colleges of Osteopathic Medicine.

Maine also ranks 11th in another widely cited – but problematic – measure of how many of the doses allocated to states have actually been injected into arms. That figure stood at 65.1 percent on Friday for Maine compared to 58.8 percent nationally.

But health officials contend those calculations create an erroneous impression that large numbers of doses are available but are not being administered, despite states’ laments of inadequate supplies. That’s because the federal government’s number of “distributed” or “allocated” doses includes second doses that have been earmarked but not yet shipped to states.

Dr. Nirav Shah, director of the Maine CDC, insists there are no vaccine stockpiles sitting around in Maine freezers.

“Those doses may not have even been made yet,” Shah said last week. “Instead, when they say ‘allocate,’ that means they have created a voucher in their system. … It’s in effect a promissory note for second doses that will be delivered three or four weeks in the future.”

According to Maine CDC’s numbers, as of Thursday morning, health care providers had administered at least 76 percent of the 169,225 first and second doses that had actually arrived in Maine. And officials point out the figure is actually even higher because CVS and Walgreens only report vaccinations at long-term care facilities every three days.

‘IT’S NOT SOME LUCKY BREAK’

Regardless of the metric used, however, it is clear that Maine leads most states but trails others in terms of speed and efficiency.

In Alaska, 12.4 percent of residents had received at least one vaccine while 3.3 percent had received both shots as of Saturday. West Virginia, which has been held up as a leader in the early vaccination effort, had delivered the first dose to 10.2 percent of residents and second doses to 3.3 percent.

One apparent key to West Virginia’s success so far is that, unlike Maine and the vast majority of other states, the Mountaineer state opted to use independent pharmacies to vaccinate nursing home residents rather than sign onto the federal partnership with Walgreens and CVS. As a result, West Virginia had completed all of its first-dose vaccinations in long-term care homes by the end of December.

“All states and jurisdictions are facing the issue of not enough supply given the huge demand,” said Joshua Michaud, associate director of global health policy at the Kaiser Family Foundation, a national nonprofit focused on health policy. “Every state is up against that.”

Maine’s allocation from the federal government was 18,550 first doses last week and is expected to climb to 20,375 this week – well short of the 50,000 weekly doses officials estimated are needed to vaccinate most Maine residents by summer.

Michaud said “there’s not just one story” about why some states are doing better than others at distributing and administering vaccines. Nor do the trends fall along easy-to-understand lines.

West Virginia, Alaska and the Dakotas are at the top of the various lists in terms of getting shots into people’s arms while other rural states, like Mississippi and Montana, are at the bottom. Likewise, populous states such as Connecticut, New York and Florida all rank above Maine, while New Jersey, New Hampshire and Virginia are near the bottom.

“It’s not some lucky break,” said Michaud. “They actually worked hard toward that goal. And I think for the states that invested earlier on, and took the time and effort to put plans in place, it shows.”

Maine Gov. Janet Mills said she believes the state is making progress despite the challenges of distributing doses in a rural state and a lack of consistency from the federal government, particularly during the Trump administration.

“You can’t just deliver a few doses here or there,” Mills said in a media briefing last week, citing the need to store vaccines at temperatures of 5 degrees and minus-112 degrees, depending on the manufacturer. “Maine has a very dispersed population, the most dispersed population in the country, so gathering people together and finding the most efficient way to disperse these new vaccines has been a big challenge. And I think we have been doing as well as we can with those challenges.”

NO STATEWIDE REGISTRATION

Maine also lacks a statewide vaccination registration and appointment system, thereby forcing hospital networks and health care systems to come up with their own processes for dealing with the deluge of queries from older Mainers to be inoculated. While residents age 70 and older represent just 13 percent of Maine’s COVID-19 cases, they account for 86 percent of the state’s 590 deaths, to date.

MaineHealth, which is the state’s largest health care network, was inundated with 70,000 calls in one day – the equivalent of one call from every resident of Portland – for just a few thousand appointment slots.

Between their ages and chronic health conditions, Marie and Dennis Buckley of York meet every criteria for high-priority vaccination. After months of isolation from nearby friends and family and little information on vaccines, the appearance of a vaccination registration website “at least told us that somebody knew we existed,” Dennis Buckley said.

The couple registered with MaineHealth after days of trying every website and phone number listed for their area. But the lack of follow-up information weeks later has them wondering whether to wait for that call, or keep trying elsewhere.

“No news is not good news, and for me the anxiety has come back,” Dennis Buckley said.

Like many states, Maine opted not to use a registration system launched by the U.S. Centers for Disease Control and Prevention late last year. Known as the Vaccine Administration Management System, the web-based system allows for patient registration and appointment-making but lacked other, back-end features that Shah said are needed for a truly efficient and integrated system.

As a result, Maine CDC is likely two to four weeks away from launching its own statewide system.

“We were hoping that the federal solution, called VAMS, would be the one-stop shop that all states could use for every single vaccine site, whether it was a pharmacy, a hospital, a doctor’s office or a large public-facing site,” Shah said. “It could preregister, register, validate, consent and do everything on the back end. It can’t do any of those things, really.”

But some states are using VAMS.

In neighboring New Hampshire, about 170,000 people had registered for appointments as of last weekend using VAMS and 160,000 had already received response emails to schedule appointments, according to news reports. But because VAMS is a two-step system, requiring registration and then a separate step for scheduling, New Hampshire officials plan to transition to another, one-step system next month.

Registering for vaccination and making appointments has been an issue across the country, with many states, including Maine, trying to launch complex, multi-layered systems in the midst of a global pandemic.

Dr. Rebecca Weintraub, an assistant professor at Harvard Medical School and leader of the Global Health Delivery Project, said distribution of a brand new vaccine is challenging under normal circumstances, much less during a deadly pandemic. Compounding those challenges, there are 64 different immunization systems nationwide and a digital health infrastructure in need of serious upgrades before COVID.

“We’ve had a year of mismanagement of the pandemic and our state leaders have had an incredible burden to pick up the slack” to respond to the virus and prepare for mass-vaccination, Weintraub said.

Shannon, the president emeritus of the American Association Colleges of Osteopathic Medicine, said he certainly understands the frustrations experienced by people struggling to get through on registration sites, much less make appointments.

“It’s difficult to design,” said Shannon, a member of the University of New England board of trustees. “But if that had been launched and crashed, as it has in other states, that would not be good.”

PARTNERS IN WAITING

Shannon pointed out that Maine lacks the “deep public health infrastructure,” such as county health departments, that other states have but gives credit to the Maine Department of Health and Human Services and Maine CDC for their coordination. To ramp up vaccinations on a large scale, Shannon said the state will need to work with pharmacies, primary care physicians, first responders, volunteers and even medical students – all efforts currently in the works.

Some private practice primary care physicians, meanwhile, are impatiently waiting for their chance to help.

“All of my patients are already registered,” said Dr. Patricia Phillips, a primary care physician who operates her own practice in Yarmouth. “I’ve got their phone numbers. I’ve got schedulers right here and I’ve got vaccinators right here, ,,, but I don’t have any vaccine.”

Phillips has identified 213 patients within her office who are over age 70 and has even prioritized those patients in descending order by age and flagged those who would be most vulnerable to COVID-19 because of their medical conditions.

They’ve stocked up on syringes, purchased extra doses of epinephrine to counteract any allergic reactions and purchased a special freezer for storing vaccines. She even sent a letter to Maine CDC officials outlining her office’s plans to conduct up to 100 vaccinations per day, primarily by delivering them to patients waiting in their cars. Other patients are so infirm that Phillips is already planning to make house calls.

But she has yet to be able to tell her patients when she might have vaccine doses on hand. Some have already given up waiting and scheduled appointments several hours away in places as far away as Greenville.

“When you have a small practice, you know your patients,” Phillips said, adding that many would rather receive shots from a trusted face than a stranger at a mass-vaccination clinic. “We’re in the middle of a pandemic. … A lot of these people are elderly, they are frail and they have a lot of health problems. So it is scary of them to go to a strange place with up to 1,000 people a day. It’s what we have been telling them not to do for months.”

Last week, Shah said the Maine CDC plans to work with private physician practices but has directed most doses, to date, to hospitals or other larger health care systems able to swiftly administer the entire batch of vaccine. Batches of Moderna contain 100 doses, while Pfizer’s batches contain more than 900 doses.

Dan Morin, director of government affairs at the Maine Medical Association, said smaller and private practices understand the supply constraints but “are looking forward to playing a much bigger role.” His organization aims to help multiple practices coordinate their efforts to stage higher-volume clinics.

“We recognize that the hospitals have more than risen to the occasion and that they have done much of the work so far, but they can’t do it alone,” Morin said.

MORE CHALLENGES AHEAD

Maine’s COVID infection rates starting to decline and prospects have improved under the Biden administration for more steady vaccine supplies. But officials caution against complacency.

“We have already come down a very long road and now we have another one ahead of us,” Shah said in his media briefing Thursday. “It’s going to take time. And so the one thing that I would ask everyone who is watching is to continue to bear with us.”

One thing that’s unclear is the potential impact of more contagious variants of COVID-19 – such as those from the United Kingdom and South Africa – arriving in Maine in midwinter at a time when most people are indoors.

Under the state’s current timeline, it likely won’t be until May that the remainder of essential “front-line” workers start getting vaccinated.  It could be more like June, or later, for Mainers under age 65 who are healthy and do not hold front-line positions. Those timeframes could shorten, however, if vaccine distributions from the federal government increase.

“From what I’m seeing, I think Maine does do well,” said John Gale, the USM Cutler Institute researcher who specializes in rural health care. “We are small enough where we can get our arms around some of the problems. We have a stable government system and folks in power who understand how this works, … so we’ve got a reasonable plan.”

But Gale said one of the next big challenges will be reaching those rural communities where access to health care is limited, transportation is a factor and many people may have problems taking off time from work. There is also the problem of vaccine acceptance among rural residents, minorities, immigrant populations and tribal members – communities that Gale said “our health systems haven’t always treated … very well.”

The keys, Gale said, will be tapping civic leaders, pastors, police chiefs and other trusted figures to help spread the word while also bringing the vaccine to people via mobile clinics, events at local spots and partnerships with area civic groups.

“If there’s an opportunity in the delay of supplies, I think it gives us time to have those discussions … and build those partnerships now,” Gale said.

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