ROCHESTER, Minn. — When Maren Schroeder got a call last week from Mayo Clinic telling her it was time to sign up for a COVID-19 shot, she was confused.
Schroeder is a paralegal who occasionally volunteers in victim services. Before the pandemic hit, she would sometimes be called to Mayo Clinic’s emergency room to meet with people who had been sexually assaulted.
She hasn’t been there since before COVID-19 hit, but she was flagged by Mayo to be vaccinated nonetheless.
Meanwhile, Schroeder was in the midst of struggling to figure out how her mother, who is 69, can get a shot under the state’s recent pilot program that allows people 65 and older to get vaccinated.
“Part of me is like, ‘I understand why as a volunteer that goes to the (emergency department) I would get a vaccine,” she said. “But I also don’t understand why we are prioritizing volunteers who may only go one, two, three times a year over these patients who really, really need it.”
Schroeder said the situation was confusing and frustrating — and stands in stark contrast to her mother’s struggle to get a vaccine, even though she’s qualified for one.
It’s not just happening to her. Around the state, health care systems have been giving vaccines to people who, according to state officials, don’t qualify for one: volunteers like Schroeder, but also people who are exclusively teleworking. In some cases, people like fitness instructors and construction workers are getting shots as well, whether they are at high risk of developing a severe case of COVID-19 or not.
State officials say their guidance is clear, that people in those categories shouldn’t be vaccinated yet. The situation underscores the extraordinary complexity of the state’s — and nation’s — vaccine rollout, raising questions about distribution, access and equity when the supply of shots still runs far short of demand.
Layers of distribution
In the state’s hierarchy of COVID-19 vaccine distribution, the state Health Department has deputized large health systems to distribute significant quantities of the vaccine — first to health care personnel who can’t work from home, and then to the wider public, as part of the public-private partnership that’s getting the shots from the government to the people who need it most.
State officials say some hospital systems around the state are taking liberties with the vaccines once they are entrusted in their possession, flouting state and federal guidance for who ought to be vaccinated.
Right now, the state has prioritized vaccinating people who provide in-person health care services or people living and working in congregate care settings. But at places like Mayo Clinic, HealthPartners, M Health Fairview and Allina Health, people who don’t have patient contact or who can work from home are getting vaccinated.
“The health systems have been far more lenient in vaccinating people than was intended, and that’s concerning,” said Minnesota Department of Health infectious disease director Kris Ehresmann. “We felt like we were pretty clear in the guidance.”
She said following the state’s guidance closely is essential to ensuring that access to the vaccine is equitable — and that it reaches the people most vulnerable to COVID-19 first.
“Our goal was to make sure that the essential elements of providing care to patients were being covered (in the first phase),” she said, “not that every person with an association with health care was vaccinated.”
In some large hospital systems around Minnesota — such as HealthPartners, which has hospitals and clinics around the Twin Cities and employs 26,000 people — some employees who have so far exclusively worked from home have been vaccinated if their work is deemed essential to the system’s hospital operations, such as information technology.
In others, like Mayo Clinic’s vast health network in the southern half of the state, people who don’t provide care to patients at all, but who may be back to work on the system’s campus within the next few months, have been getting shots or are scheduled to get them.
Those include people who work at Mayo’s employee gym and community wellness center, parts of which are currently closed; construction workers on contract for Mayo projects; onsite employee credit union workers and others, like Schroeder, who work as occasional volunteers.
Hospital systems say making sure staff and patients remain safe requires fast and widespread vaccination among their staff.
And they say the state’s guidance was poorly defined from the start, leaving it open to interpretation — which many systems have applied broadly. A line in the state’s early vaccine rollout documentation that “people not directly involved in patient care, but who could be exposed to infectious agents that can be transmitted in the health care setting” has frequently been applied to anyone coming on to their campuses to work.
Health system leaders say confusing and frequently changing instructions from state and federal authorities have challenged their own internal vaccination strategies. And they argue that getting too bogged down in the details of which employees meet the criteria for vaccinations — and which don’t — would have further hampered an already slow vaccine rollout that has met with significant public complaint.
State rollout based on federal guidance
Minnesota’s guidance around who should get the vaccine shots first is based on recommendations from the federal Centers for Disease Control and Prevention, and it’s divided into three priority groups, including health care providers, and long-term care workers and residents.
Right now, the state is focusing on the tail end of that first priority group, which includes health care providers in private practice — like doctors and ophthalmologists — in-home nurses and retail pharmacists.
That’s in addition to a pilot program the state is running simultaneously, for people 65 and older and a limited number of educators and child care workers. Earlier this month, the state expanded eligibility to these groups in an effort to speed up vaccinations and comply with federal guidance.
In some parts of the state, those private practice providers, in-home nurses and others are already being vaccinated through local public health offices and health care systems, which have served as hubs for vaccine distribution.
But in other parts of the state, Ehresmann said, vaccine distribution to health care providers who aren’t with large health care systems, and among vulnerable adults living in group homes, has been slow and uneven in part because hospitals have been focusing on vaccinating members of their own staff who, she said, don’t qualify for shots yet under state guidance.
Dr. Stanley Perlman, a professor of microbiology and immunology at the University of Iowa, serves on the CDC’s Advisory Committee on Immunization Practices — a group of vaccine experts who made recommendations to the federal agency on how the COVID-19 doses should be distributed. It was the ACIP’s guidance that Minnesota health officials eventually adopted as their own.
Perlman said the group debated how prescriptive it should be in its recommendations.
On one hand, he said, being too specific about who should be vaccinated, and when, would slow the rollout of the vaccine; hospitals would need some flexibility on who to give shots to because public health officials don’t want to waste doses.
But on the other hand, Perlman said, guidance that’s too broad would likely lead to a less equitable rollout, with people in positions of power having greater access to vaccines than those who aren’t. He pointed to the situation unfolding in Florida, where federal guidance was largely ignored, leading to a disorganized — and haphazard — vaccine distribution.
“The health systems have been far more lenient in vaccinating people than was intended, and that’s concerning. We felt like we were pretty clear in the guidance.”
— Kris Ehresmann, Minnesota Department of Health infectious disease director
By design, the federal and state guidance is meant to steer hospitals and public health authorities toward making sure people who are at the highest risk get vaccinated first.
Perlman said the guidance inevitably has some gray areas — for instance, there are always people who work daily in a hospital who aren’t health care providers and have no patient contact — like environmental services, cafeteria staff and maintenance workers. And those workers may still be at higher risk of being exposed to the virus than their counterparts who do patient-focused work, but remotely.
The guidance also had to be flexible enough to accommodate people who aren’t doctors or nurses, Perlman said.
“There are people who clean the rooms, and who are actually at high risk of getting infected. They’re definitely people we would put in the 1a category (which is the state’s highest priority group of vaccine recipients), even though they don’t take care of patients, per se,” he said.
The state health department has said that, at all major Minnesota hospitals, employees on the front lines of COVID-19 care — ICU doctors and nurses, and the housekeeping teams who support them — have gotten at least one dose of the vaccine, if not both, by now.
But beyond that, Perlman said he is seeing inconsistent interpretation nationwide among hospitals about which staff members beyond frontline workers qualify for a shot.
“As you get further down that tree, though, it’s going to be more difficult to justify those people getting vaccinating very early on,” Perlman said. “The IT people, especially someone working from home … that’s not someone who has any risk.”
At HealthPartners, for one, some teleworkers — including people working in the company’s information technology department — have been vaccinated, said spokesperson David Martinson.
“There are instances when colleagues who work in roles without direct patient interaction have received vaccines because they are critical support to our patient care teams and functions that are essential to our ability to keep our health system operating,” said Martinson. “These team members include many roles, from environmental services to supply chain to contact center staff to information technology.”
Allina Health, which runs hospitals and clinics in the Twin Cities metro area, says it “has offered the vaccine to all patient-facing employees,” in addition to all its health care workers — but a spokesperson did not specify whether that group includes staff who don’t interact with patients in person.
Meanwhile, M Health Fairview, another Twin Cities provider, is only offering vaccinations to those who need to be on campus for work, even if they aren’t engaged in direct patient care, said spokesperson Aimee Jordan.
In recent weeks, all three institutions have started offering vaccinations to some patients over 65 and to health care providers in the community who are unaffiliated with a specific hospital or system.
The ethics of getting vaccinated
The situation has left some employees of the state’s largest health care systems scratching their heads — and worrying over ethics.
In Rochester, a Mayo Clinic employee who has worked exclusively from home since the start of the pandemic is weighing whether he should get the COVID-19 vaccine, which he’s signed up to receive later this week. He’s not sure when he will be back on Mayo’s campus to work.
His wife, who works in dentistry, is at higher risk than he is because she is in daily, close physical contact with patients who may have COVID-19 and not know it. She is a member of the state’s Phase 1a priority group, who are eligible to receive the vaccine right now, but is still waiting to hear how and when she will get it.
“If I could not get it and give it to a senior citizen, I would. Because frankly, everyone is more high-risk than I am,” said the Mayo employee, who didn’t want to give his name for fear of retribution at work. “I one hundred percent should not be getting this shot now.”
Dr. Melanie Swift, who is leading Mayo Clinic’s vaccine rollout, said that teleworkers are not eligible to get shots yet. But she said that some teleworkers may have been scheduled for shots because their supervisor flagged them as someone who might end up working back on the clinic’s downtown Rochester campus in the next couple of months.
Mayo, Swift said, is shifting its vaccination focus to patients older than 65, and to other providers in the community who are at high risk of COVID-19 exposure. She says about 8,000 people of the 39,000 who work at Rochester’s Mayo campus still haven’t received the vaccine.
“It’s kind of an inevitable messiness, when we have evolving clarifications on the guidance,” said Swift. “It’s not a perfect system. We’re trying to manage 72,000 people [across all of Mayo’s campuses in Minnesota and elsewhere] rapidly. It’s not going to be 100 percent perfect, but it is a good-faith effort to assess people individually and not just make assumptions about a job title.”
And if the state doesn’t want Mayo to be vaccinating people who aren’t health care providers on campus to work, she said, it needs to make that clear in its guidance, which currently states that “people not directly involved in patient care, but who could be exposed to infectious agents that can be transmitted in the health care setting” can be considered part of the first group of vaccine recipients.
Ehresmann said state Health Department staff doesn’t have the capacity to respond to each discrepancy in systems’ vaccination plans, and it can’t penalize its partners for flouting it.
But the department has begun shifting vaccine supply away from hospital systems and toward clinics that aren’t associated with big systems, so vaccines can be given to older residents. In the meantime, the state has been watching vaccination rates and usage by its partners closely.
“The vaccine that we have been given is a public trust, and a public resource,” she said. “Our goal has always been to immunize for impact. We have counted on partners to do that … and we would just ask our partners to refocus on making sure the vaccine is getting to those who are most vulnerable and need it the most.”
Ehresmann said that every time a hospital gives a vaccine to an employee who shouldn't be getting one, it's one less vaccine available for these highest-risk individuals.