The Vaccine Rollout in Rural Alaska—Coordination and Communication Made Getting Back to Business Possible

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.

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.

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.

“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.