The Vaccine Rollout in Rural Alaska—Coordination and Communication Made Getting Back to Business Possible
According to Yukon-Kuskokwim Health Corporation (YKHC) Chief of Staff Dr. Ellen Hodges, the planning, coordination, communication, and dedication that made the vaccine rollout in rural Alaska a success story is striking.
“That project was the most extraordinary project I have ever had the honor to be a part of. We got vaccine out to forty-six villages in something like ten days,” Hodges says. “Everybody kind of had to all be on the same page and all pull together in the same direction for this to be successful.”
In December, vaccines were rolled out to some of the most remote parts of the United States, providing vulnerable populations access to vaccination to help prevent a fragile healthcare system from being overwhelmed.
In the Yukon-Kuskokwim Delta, the distribution was named Project Togo. While Balto led the pack the final miles to Nome in 1925 with life-saving antitoxins to end a diphtheria outbreak, it was Togo who had done the heavy lifting.
“It was actually Togo who led the team most of the way, kind of the unsung hero of the Nome serum run,” Hodges says.
Though the first Pfizer vaccines were rolled out to villages off the road system in December, planning started months earlier.
“We wanted to lay the groundwork, as much as possible, so that the geography, distance, and sheer size of Alaska was not going to be something to hold us back,” says Alaska Department of Health and Social Services Commissioner Adam Crum, noting that the state started planning its vaccine distribution in August.
“I think there was incredible effort to get vaccine availability early into rural communities,” says Dr. Robert Onders, the Alaska Native Medical Center administrator and liaison to the state for the Alaska Native Tribal Health Consortium.
He explains there are three primary factors that allowed rural Alaska to successfully distribute vaccines during the pandemic: the federal government providing separate allocations of vaccines to tribal organizations, Alaska Native tribal organizations coordinating efforts with the state of Alaska, and a reliance on local knowledge for distribution.
“They actually moved vaccine around the state in such cool ways: by bush plane, by helicopter, by dog sled and four wheeler,” Crum says. “It was just such an Alaskan thing to do … no matter where you’re at, we’re gonna find a way to get there.”
Effect on Alaska Natives
Getting vaccines to these rural communities was important because they were home to particularly vulnerable populations with limited access to intensive care units. A study by the Centers for Disease Control and Prevention found that American Indians and Alaska Natives were 3.5 times more likely to contract COVID-19.
“Alaska Natives shouldered a disproportionate burden of this disease. They were infected at higher rates, and when infected we’re more likely to be hospitalized and more likely to die at much higher rates,” Hodges says. “So it was important to get that very vulnerable population vaccinated as soon as possible because of those additional risk factors.”
Those risk factors are compounded by the lack of adequate housing and lack of quality water sources in some of Alaska’s rural communities, explains Onders.
When briefing his team, Governor Mike Dunleavy made them aware of the impacts the 1918 pandemic had on the Alaska Native population, Crum says.
“We knew that it was important to make sure that this population was both educated about the vaccine and had easy access to it because this is one of the high-risk groups we want to make sure was protected,” Crum says.
Who Got the Shot
“Alaska tribal health organizations were eligible to get a specific distribution through the Indian Health Service,” Onders says.
Hodges says YKHC received vaccine allocations from both the state and Indian Health Service. However, these vaccines came with different guidelines for administration: all state-issued vaccines were to be used strictly within the state guidelines, while there was more flexibility for the use of Indian Health Service vaccines.
“The state vaccine was only to be used for the categories that the state was on. So, if they were on tier one, group A—that’s who would get the state vaccine,” Hodges says.
For the Indian Health Service vaccine, the instructions for tribal health organizations were “to do the most good to the most people.”
Additionally, “The rollout was not limited to Alaska Native people for the tribal allocation,” Onders says. “They could create their own local allocation priorities.”
“There was a huge push to get our healthcare workers and first responders vaccinated and then almost immediately pivoting to elders because we had such good vaccine supply,” Hodges says.
The flexibility granted through the Indian Health Service allocations created a dynamic that allowed local health organizations to focus on the safety of entire communities, and Onders says this option was particularly important when delivering doses to difficult-to-access, rural communities with small populations.
“If you’re going to make the effort to go there and have a vaccine clinic, make it eligible to everyone at that time because you can get it done in that single instance,” Onders says.
Exactly how that flexibility was used came down to each of the twenty-seven different tribal health organizations in the state.
“Certain communities were able to do this broadly. You know, if it was important for that community in that village to make sure that the VPSO [village public safety officer] or the state trooper or the fish and game representative got access to the shot, they made that available,” Crum says.
“On the state side, we just respected whatever their decision making criteria was for getting that shot in arms.”
Hodges says that YKHC was aware of the energy and thoughtfulness put into developing the Alaska vaccine distribution tier system, so they followed that system—they were just able to move through it much more quickly.
Same Partners, New Product
The coordination between tribal health organizations and the state is an extension of established reporting, ordering, and distribution systems.
“Alaska has been working with tribal health organizations to distribute childhood vaccinations to all these remote communities for years,” Onders says. “I think that allowed for a more rapid distribution to these communities… people didn’t have to learn a new process, a new supply chain.”
But the vaccines themselves changed some processes; early on it became clear that the Pfizer vaccine came with challenging handling components.
“[Project Togo] was the most extraordinary project I have ever had the honor to be a part of. We got vaccine out to forty-six villages in something like ten days.”
Aware that Pfizer was most likely to be the first vaccine approved, YKHC’s initial planning integrated the fact that it was a “fussy” vaccine, Hodges says.
Pfizer needs to be kept at -70°F, must be used within five days once it has been brought up to room temperature, and can be damaged by too much jostling.
“We’re always getting vaccine out to rural areas, but this one was special,” Hodges says.
Additionally, because of the risk of anaphylaxis, YKHC shifted their plans to ensure health providers and nurses traveled along with every dose during Project Togo.
Keri Zimmer, Kodiak Station Manager unloads COVID-19 vaccine in Kodiak.
Planes and Planning
Once the initial load of vaccines arrived in Bethel, where YKHC is headquartered, they were loaded into charter planes. The distribution team had a list of villages the team was going to visit that day—some had twenty-five people who needed to be vaccinated, some only had one, Hodges says.
Onsite community health aides contacted locals to determine exactly how many doses were needed in each village on each run, minimizing waste, Onders says.
“We saw very little to no wastage, which is incredible as well,” Onders says. “I think it is about the connection with the local people who know the supply chain and know how best to get things there in the time needed.”
Locals in the village organized those getting vaccinated, meeting the plane on the tarmac. Patients were vaccinated in their trucks, on their four-wheelers, on their snowmachines, even in the plane itself, Hodges says.
The plane and medical team leapfrogged from village to village, waiting about twenty minutes after the last dose was administered to ensure patients were safe.
Unlike other tribal health organizations, which had teams make vaccine runs by dog sled, snowmachine, helicopter, and float plane, YKHC mostly stuck to charter flights in the beginning.
“That’s just the most expeditious way to get to as many villages as possible,” Hodges says, noting that some of the nearby villages were accessed by ice road.
Bad winter weather often delayed flights, complicating the rollout.
“Think of it as a continuously moving sort of game of three dimensional chess,” Hodges says. “It was constant communication, constant planning to get the vaccines out in a timely fashion.”
This coordination in some of the most unpredictable, roughest conditions in the United States was only possible because of the level of communication between all parties.
“I can’t say enough about our partners that helped out with this,” Hodges says, pointing to the extraordinary support of the state, Indian Health Service, airlines, pilots, and healthcare providers.
Early Success on a Long Road
At the height of the outbreak, the Yukon-Kuskokwim Delta region had the highest case rates in the nation.
“We have a very fragile healthcare system,” Hodges says. “It was real dicey there, especially in November and December, when we were at the height of our outbreak… We were very, very close to being overrun.
Those numbers have come way down since the launch of Project Togo.
By the end of April, approximately 65 percent of the eligible population was vaccinated in the Yukon-Kuskokwim Delta region. Even better, some rural villages, such as Mekoryuk, were at a vaccination rate of nearly 100 percent.
Alaska Airlines’ passenger and freighter fleets played a role in the safe movement of COVID-19 vaccines to remote locations throughout the state.
“Because we were so good at getting shots in arms in the vulnerable populations up front, our hospitalization numbers bear that out,” Crum says. “We have been at low levels of hospitalization now for months.”
While the efforts of Project Togo and other vaccine distribution efforts in rural Alaska have been hailed an overwhelming success, healthcare providers say there is more work still to do.
Tribal health organizations and the state are now focused on reaching out to individuals who are eligible for the vaccine but haven’t gotten it yet.
“Our big push is trying to get that next group of people who are either ambivalent or don’t want it because they are healthy and not in a high-risk group and to talk to them about what the benefits are and just give them the education necessary so they can make a personal choice,” Crum says.
“We wanted to lay the groundwork, as much as possible, so that the geography, distance, and sheer size of Alaska was not going to be something to hold us back.”