Brian Marden rolled a luggage cart with 550 doses of Johnson & Johnson vaccine into a Maine Medical Center parking lot last week, readying them to be moved from the Portland hospital to the Scarborough Downs mass vaccination clinic.

The doses were packed in a blue and white cooler, the kind that one would take for a picnic, except this cooler featured a temperature display on the outside to monitor how cold the doses were staying, and carried disease-preventing medicine instead of ham and turkey sandwiches.

Marden placed the cooler and several cardboard boxes of vaccine supplies – including syringes, immunization cards, masks, gloves and face shields – in the back of his dark green 2018 Jeep Wrangler, a makeshift dose-mobile.

He was on the vaccine road again.

The process of moving doses from place to place to find the best match of supply and demand is a crucial and often overlooked component of Maine’s vaccination program. If the state gets a 50,000-dose shipment from the federal government one week and then decides by Thursday where those doses are going, that’s not the end of the process, it’s only the beginning. Doses are constantly being shifted from one clinic to another throughout the week by a fleet of Maine CDC vans or health care systems using their own vehicles.

“It’s like a big chess game, where we keep moving pieces around, doing what we need to do,” said Tonya Philbrick, director of the Maine Immunization Program at the Maine CDC. “At any time throughout the process, we can transfer vaccines to other parts of the state where there is a greater need.”

Marden, senior director of pharmacy at Maine Medical Center, decided to do most of the dose shifting himself for MaineHealth, which operates the Scarborough Downs and Sanford mass vaccine clinics, and numerous clinics in other locations throughout much of the state. The Scarborough Downs site began offering the one-shot J&J vaccine starting this week.

He said if MaineHealth, the parent company of the hospital, had outsourced the work, too much could have gone wrong with the doses, which require specialized handling and cold storage. Johnson & Johnson can be kept at warmer temperatures – on Friday they were at 5.8 degrees Celsius, or about 42 degrees Fahrenheit in the cooler. But the other vaccines in use, Pfizer and Moderna, require strict cold storage below freezing.

“I just felt an overwhelming sense of responsibility to get this right, to own it,” Marden said. So Marden has spent four to five days per week shuttling doses all over the state, including his longest trip, picking up 1,170 Pfizer doses from A.R. Gould Hospital in Presque Isle, an eight-hour round trip in December.

Between Marden’s Jeep and a few other employees who have pitched in to help ferry vaccines, MaineHealth has moved about 250,000 doses more than 17,000 miles. Maine has given more than 1.2 million doses of the vaccine since shipments started arriving in December.

DECIDING WHERE THE DOSES GO

At the Maine CDC, a handful of state officials pore over spreadsheets, federal databases and requests from health care providers, deciding where to send the doses every week. Even after decisions are made on where to ship doses to on Thursday – a list that’s published publicly by the Department of Health and Human Services – officials work continuously after that to rebalance supplies to meet demand.

“It’s like a treadmill that we are always on,” said Dr. Nirav Shah, director of the Maine CDC.

Shah said that they move doses frequently every week, a constant “load balancing” that he believes is one of the keys to getting shots into arms quickly. The state is the fastest in the country at fully vaccinating its population, according to the Bloomberg vaccine tracker, with 43.7 percent of the state’s 1.3 million population having received final doses of the vaccine as of Monday morning.

Part of the calculus is a report that Shah sees every morning from the previous day’s throughput at all the vaccine clinics across the state. Shah said he scans those reports for unused doses.

“I have a distaste for vaccines sitting around,” Shah said. “If we see something doesn’t seem right, I will send them a curt email. ‘What’s going on? Why do you have X number of doses on hand?'”

If the answer means there’s going to be excess doses, Shah said that means some of the vaccines will be transferred to another location.

Philbrick, the director of the Maine Immunization Program, said 20 times or more per week the Maine CDC is moving doses around, not counting dose transfers within health care networks, such as MaineHealth or Northern Light moving doses between their own clinics.

Between the Maine CDC, the Department of Transportation and the National Guard, about 60 to 70 people assist with the logistics behind moving doses around the state, Shah said.

He said sometimes a site has too little vaccine, which also causes the Maine CDC to spring into action.

“We get a lot of requests from a clinic who may ask is there any way we can get 70 doses so we don’t have to turn anyone away and cancel appointments,” Shah said. “We will make it happen, so we might take 10 from here, 10 from here and 15 from there, and put it together.”

SHIFTING DEMAND AND SUPPLY

The immunization program has gone through several phases. In the early weeks in December and January, with limited supplies and only certain groups, such as health care workers, eligible to receive the vaccine, there was an urgent need to immunize front-line health care workers and nursing home residents and staff, but not a crush of demand from the general public, because they were not yet eligible.

As the Mills administration expanded eligibility in February but with supplies still tight, Shah said the most difficult times were in late February and early March, when clinics wanted a lot of doses, but the state didn’t have much to dole out.

“It was wrenching to say, ‘Sorry, you’re not getting all the doses you need,'” Shah said. “No one was getting the doses they wanted.”

Philbrick said to prepare for the arrival of vaccines, the Maine CDC began having weekly calls with health care providers in Augusta to work through issues and to be transparent about how the dose allocation process was going to work. Health care providers had to fill out detailed applications so that the Maine CDC could see what the vaccination capabilities were at each clinic. That helped the state agency know how to allocate and move around doses, Philbrick said.

Dr. Joan Boomsma, chief medical officer for MaineHealth, said earlier this year that vaccine doses were primarily being shipped to Maine Med in Portland, but they wanted to make sure the vaccine was getting to other places. MaineHealth has seven hospitals in Maine, including in Brunswick, Norway, Farmington, Rockport and Belfast.

“We didn’t think everyone should have to drive to Portland to get a shot just because that’s where the vaccine got delivered,” Boomsma said. But now with more supplies, the doses are being shipped from the federal government directly to MaineHealth clinics throughout the state.

Currently, with flush supplies and weakening demand, the strategy has shifted.

“Now we have to find where those pockets of demand are and satisfy those demands. There are still intense areas of demand, such as colleges and universities,” Shah said. Also, the federal government on Monday approved the Pfizer vaccine for the 12-15 age group, which also could help with demand.

At Scarborough Downs, Marden said one reason MaineHealth moved Johnson & Johnson doses to the mass vaccination site was to try to boost demand. The one-shot J&J vaccine is more convenient because a second dose is not needed. With Scarborough Downs now accepting walk-ins, Marden said the hope is that the convenience factor will help with demand. Those 18 and older can stop by Scarborough Downs without an appointment, get the one-shot J&J vaccine and be “one and done,” Marden said.

The Scarborough Downs site, which opened Feb. 3, was doing about 2,500 vaccinations per day at its peak, but is currently doing a little under 1,000 per day.

After he arrived at the Scarborough site last week, Marden put the doses in a refrigerator in the room where the staff prepares the vaccine. The doses were stored at about 4 degrees Celsius, or 40 degrees Fahrenheit, in preparation for being used this week.

He took the empty cooler to pack into the Jeep, exited the back door of Scarborough Downs, overlooking the defunct racetrack, and headed back to Maine Med.

Another day, another successful shipment.

Soon enough, he would be back on the road, doing his part to carry life-saving vaccines to all corners of Maine.

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