Maine is immunizing its population against COVID-19 at a faster clip than any state in the nation. Yet a look below the surface of statewide data reveals stark differences in vaccination rates between urban and rural areas, large pockets of unvaccinated people among age groups and significant gender gaps.

These gaps illustrate the challenge that lies ahead as Maine and the rest of the nation strive to hit the 75 to 85 percent inoculation rate experts say is necessary to curtail transmission and defeat the virus through herd immunity.

An analysis of data reveals major successes in the state’s four-month-long vaccination campaign – including a 39 percent full inoculation rate that is nearly 10 points higher than the national average – but it also exposes troubling trends.

These include:

• Men in their 50s living in Cumberland County are more than twice as likely to have received at least one shot than their similar-aged counterparts in Somerset County. For men in their 20s, the difference is threefold in the two counties.

• Androscoggin County has among the nation’s highest rates of new COVID-19 cases but the second-lowest full vaccination rate in Maine.

• Despite a nearly four-month-long campaign to protect Maine’s vulnerable older residents, 25 to 30 percent of those age 70 or older in some rural counties have yet to be vaccinated against COVID-19.

• Only one-third of Mainers under 30 – the age group driving much of the recent surge – has received at least one dose, and just 15 percent are fully vaccinated.

• York County continues to lag behind other coastal counties despite increasing access to clinics.

With all the proverbial “low-hanging fruit” now plucked, public health officials armed with steadier supplies of doses are shifting tactics to target those harder-to-reach population segments.

“We are just beginning to understand how people will approach the COVID-19 vaccine when there is full access to it,” said Dr. Laura Blaisdell, a pediatrician and vaccine expert from South Portland.

Cumberland County, the state’s most populous, leads Maine with 57.5 percent of its residents receiving at least the first dose of the vaccine, while the least-vaccinated county, Somerset, had only 31.4 percent of its population with at least a first dose – a yawning 26.1 percent gap.

Other rural counties, such as Oxford and Franklin, also had first-dose vaccination rates under 40 percent, while coastal counties Lincoln, Sagadahoc and Knox had first-dose rates above 50 percent.

With some age groups the disparity is even greater, such as among those in their 50s, of whom 72.4 percent have received at least the first dose of the vaccine in Cumberland County, compared to 36 percent in Somerset County and 43 percent in Piscataquis County.

ACCESS AND HESITANCY

Public health experts say now that vaccine supplies are more plentiful, there are two primary explanations for these gaps – access and hesitancy.

“We’ve gotten through the eager, and the willing,” said Dr. Noah Nesin, chief medical officer at Penobscot Community Health Care, a community clinic in the Bangor area that is vaccinating thousands per week. “We are working on the hesitant. The final gasp will be the resistant.”

To reach those who will get immunized but not if they have to go out of their way to do it, the clinic has begun offering vaccinations on Saturdays and bringing vaccine to small towns like Jackman, Winterport and Old Town as well as students at the University of Maine. Nesin said PCHC has also been targeting vaccinations for the homeless, people in jails and people living in senior housing and low-income housing.

The idea is to pick locations where people are comfortable and around their peers, such as churches and the Islamic Center in Orono.

“For some people, they may be (averse) to going to a big mass vaccination center like Cross Insurance Center in Bangor, there may be transportation issues and trust issues, so doing it in a familiar site is helpful,” Nesin said. “Hesitancy is easier to overcome in smaller, more familiar places.”

PCHC is also giving doses to homebound seniors, a group that has been difficult to reach and that numbers suggest are still largely unvaccinated, particularly in rural areas. For example, while more than 90 percent of Mainers age 70 or older in Cumberland, Lincoln and Sagadahoc counties are fully vaccinated, that figure falls to 69 percent in Piscataquis and 75 percent in Somerset and Oxford counties.

Nesin said the clinic is also working on public education outreach efforts, such as Facebook Live events, where the staff fields questions about the vaccines, to let people know they are safe and effective.

“We get the full range of questions, including very specific science-based questions, and also questions from people asking whether the vaccines alter their DNA or will have microchips implanted in them,” Nesin said, referring to two common false myths about the vaccines that have been spread online. “We answer all questions seriously so people aren’t embarrassed or shamed.”

Dr. Nirav Shah, director of the Maine Center for Disease Control and Prevention, has said his agency works to provide information and answer questions for those who are hesitant to receive a vaccination.

“But our main focus right now is convenience,” he said in a media briefing last week. “Can we offer more walk-in hours? Can we offer early-morning and later-evening hours for those who have to work? Can we get as much J&J vaccine into the state?”

In Norway last week, a vaccine clinic was set up in the basement at the Ripley Medical Office Building next to MaineHealth’s Stephens Memorial Hospital. The sparse room accommodated a steady flow of people getting their Moderna vaccine, a mix of ages and people who made appointments and walk-ins. During an hour of operation, about 20 people were immunized by a crew of staff and volunteers.

Jennifer Fogg, 36, of Norway said she overcame her hesitancy about the vaccine to walk in and get her first dose.

“I was hesitant but I was never like ‘I’ll never get it.’ I was hesitant just because it’s a new vaccine and I wasn’t sure what to expect,” said Fogg, who works in marketing at the hospital.

But Fogg said people working in health care that she trusted encouraged her to get the vaccine, and she realized that if she was trusting them for other medical advice, she should listen to them about vaccines. The convenience of the walk-in clinic also helped.

“The fact I didn’t need to wait another two weeks after making an appointment was good for me psychologically. I could just walk over and do it,” Fogg said.

Fogg said she’s “kind of excited“ now that she got vaccinated.

“My mindset has changed and now I’m proud of being part of this and being part of the solution to get everything back to normal,” she said.

YOUTH RATES LAGGING

The last four weeks have seen dramatic progress in Maine’s vaccination campaign but also disturbing developments with COVID-19, particularly in youth infection rates.

Maine consistently had among the country’s highest rates of new cases throughout April, driven largely by a surge in cases among people under age 30. And the epicenter of that new surge has been in Androscoggin County, with the Lewiston-Auburn area having the nation’s third-highest daily case rates over the past two weeks among metropolitan areas with at least 50,000 residents, according to tracking by The New York Times.

Statewide, just 35 percent of residents between the ages of 16 and 29 had received at least one dose of vaccine as of Friday and just 14.6 percent had received all of the required doses for full vaccination, according to Maine CDC data.

Cumberland County, which has the largest population of people under age 30, is doing the best, by far, with 47.8 percent of younger people having received at least one dose and nearly 18 percent fully vaccinated. All of the coastal counties, with the exception of Waldo and Washington, along with Androscoggin County, have first-dose rates for younger residents that are between 30 and 35 percent but final dose rates in the teens.

In Piscataquis, Washington and Somerset counties, just 20 percent or less of residents under age 30 have received at least one dose.

On Thursday, Shah made his most direct appeal to date to younger Mainers, saying that “every person who gets the shot gets us that much closer to being done with the pandemic.” His plea came after Maine saw two individuals in their 20s die after contracting COVID-19 and at a time when many vaccination sites are offering walk-in clinics and expanded hours to draw more interest.

INCENTIVIZING DOSES

Although older age groups more at risk from hospitalization or dying of COVID-19 were generally very eager to get vaccinated, younger people have been more willing to wait on getting their shot, said Blaisdell, the South Portland pediatrician.

“For younger age groups, convenience is king and it hasn’t been particularly convenient to date to get a vaccine,” she said. That is changing as more vaccination sites allow walk-ins and the immunization effort broadens.

Blaisdell said other states have taken “brilliant” approaches to incentives, including Michigan, which has tied reopening and the lifting of pandemic restrictions, such as masking, to the percentage of the population vaccinated. In West Virginia, younger people are getting $100 savings bonds if they get their shots.

Some private companies have also offered financial incentives to employees who obtain vaccinations. Tractor Supply Co., for instance, offered workers $50 plus time off, as needed, for getting shots while Bangor Savings Bank offered its employees $500 once they are fully vaccinated.

“It’s the carrots and sticks approach,” Blaisdell said. “You want it to be worth it to people, so you give people many incentives to vaccinations, or make it super inconvenient to not do it.”

RURAL SUCCESSES

Not all health professionals believe incentives are necessary or always helpful, particularly when dealing with rural, close-knit communities.

“In this area, it doesn’t matter how much you give people – if they don’t want it, they don’t want it,” said Todd Phillips, a registered nurse leading Millinocket Regional Hospital’s COVID-19 vaccination effort.

In fact, the Millinocket region appears to be bucking the urban-vs.-rural trend playing out elsewhere in Maine.

As of April 24, Millinocket Regional Hospital had administered enough shots to fully vaccinate 5,571 people. That equates to 53 percent of the population in the hospital’s primary and secondary service area – a chunk of rural northern Maine stretching from Mattawamkeag to Island Falls in southern Aroostook County – and is 17 percentage points higher than Penobscot County as a whole.

“It’s not like it’s over. There is still a lot of work to do,” said Phillips, the hospital’s infection preventionist. “But our effort here in Millinocket is to try to find people where they are, … and from the beginning, a lot of it has been education and to try to battle vaccine hesitancy in our area.”

For Phillips, that started with the hospital’s own staff in November weeks before vaccine doses even started arriving in Maine. He surveyed staff and then used those responses to address the speed of the vaccine review process, whether the vaccines are safe for pregnant women (they are) and other concerns. Millinocket Regional now has a nearly 97 percent vaccination rate among staff.

Phillips and his small team then shared those same dispatches with local school leaders and began preregistering teachers for vaccination even before Gov. Janet Mills expanded eligibility to educators. As community vaccinations expanded, Phillips’ team recruited town offices to register local residents, set up clinics with local fire departments and worked with local “media partners” to educate the public.

And when people showed up for their shots – some of them still hesitantly – they were met by familiar faces, including well-known retired doctors and nurses who volunteered at the clinics.

RATES OF VACCINE MISTRUST

Mistrust in the vaccine is likely to become more evident as the number of willing recipients declines. But federal data suggests the issue of vaccine hesitancy may be less pronounced in Maine than in most other rural states.

Between 11 and 14 percent of Maine’s population was estimated to be vaccine-hesitant, according to data published by the U.S. Centers for Disease Control and Prevention based on March 2021 surveys of households nationwide.

York, Cumberland and Sagadahoc counties were all on the lower end of that spectrum, while all of counties along Maine’s western, eastern and northern borders, as well as Piscataquis, were pegged at 14 percent. The rest of the counties – Androscoggin, Kennebec, Penobscot, Lincoln, Knox, Waldo and Hancock – fell in between at 13 percent hesitant, according to the U.S. CDC.

Although higher than every other New England state except New Hampshire, Maine’s estimated vaccine hesitancy rate is lower than almost every other state outside of the Northeast. And in more than 500 counties nationwide, much of them concentrated in the deep South and the northern Plains, vaccine hesitancy topped 25 or 30 percent.

Blaisdell, the South Portland vaccine specialist, said as more people receive vaccinations and the benefits become more apparent, people become comfortable with the vaccines. She pointed to the chickenpox vaccine as an example of a shot now administered widely after initial hesitancy.

“I hear a lot of people saying, ‘It’s too new, it’s too new,’” Blaisdell said. “But eventually it gets accepted.”

POLITICAL INFLUENCE

Unfortunately, not even the fight to vaccinate the U.S. out of the COVID-19 pandemic has escaped this nation’s deep (and debilitating) partisanship.

Survey after survey across the country finds that Republicans are less likely to express a willingness to be vaccinated than Democrats or independents.

The ongoing COVID-19 vaccine monitoring program run by the Kaiser Family Foundation, a health policy nonprofit, has found that 29 percent of Republicans indicated they would “definitely not get the vaccine” – up from 25 percent in January – while 6 percent would only receive a shot if required. Those same figures were 5 percent and 3 percent, respectively, among Democrats. The vaccine refusal rate is highest among Republican men.

Public health experts in Maine caution that access to vaccine clinics, both in terms of geography and convenient timing, are likely the biggest factors for why more rural counties have lower vaccination rates.

“There may be a part of that that is reluctant or hesitant,” said Maine CDC’s Shah. “Right now, what I am seeing in large measure is not so much driven by hesitance or reluctance. It’s driven by convenience.”

There is no denying, however, that Maine’s vaccination rate map overlaps rather neatly with the state’s political map, as measured by the past two presidential elections.

Democrats Joe Biden and Hillary Clinton won eight of the nine Maine counties with the highest percentages of individuals who have received at least one shot while seven counties that supported Republican Donald Trump in both elections are at the lower half of the list. The only exception is Penobscot County, which voted for Trump but has higher first-dose rates than Democratic-leaning Waldo and Kennebec counties.

The picture is a bit more mixed when looking at fully vaccinated rates. While the Democratic strongholds of Knox, Cumberland and Lincoln counties have the highest full-vaccination rates, Trump-backing Washington, Aroostook and Penobscot counties are also in the top half.

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