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Rural Alaska is getting Covid-19 vaccinations right. Here's what the rest of the US can learn

(CNN) The immovable challenges of living in Alaska would, in theory, make it a nightmare to vaccinate all of its 731,000-plus residents: It's the largest state in the US in terms of land size, has some of the most extreme weather of any state and many resident Alaska Natives, who are disproportionately dying from Covid-19, live in the remote reaches of the state.

And yet, at 40 doses administered per 100 people, Alaska is one of the leading states in the US when it comes to Covid-19 vaccinations.

In many ways, Alaska was already prepared for a massive vaccine rollout -- they've used similar methods to deliver the flu vaccine statewide. But much of its success is by learning on the fly, coming up with creative ways to get vaccines into arms and prioritizing the state's most at-risk residents.

What works in Alaska won't work everywhere -- it's over 660,000 square miles, after all, and not every state requires health care workers to travel by dog sled to administer vaccines. But the rest of the US can take cues from the state's unique approach to its unique problems.

It has a robust public health system

Alaska's public health structure was built for complications -- its size and tendency for inclement weather require it. So when it came time to start vaccinating residents, the state didn't have to build a robust public health system from scratch like some others, said Dr. Anne Zink, Alaska's chief medical officer.

Zink credits the state's success to its "hub-and-spoke" model of health care: The "hub" -- Alaska's Department of Health and Social Services -- gives local health care providers, or the "spokes," the resources they need. But because Alaska is such a varied state, it's up to local providers on how to use those resources to best serve residents.

Alaska's public health system was prepared to deliver vaccines to remote reaches of the state.

A localized approach to vaccination hasn't worked everywhere, but it's worked in Alaska, Zink said. The state distributes vaccines to different regions but doesn't give directives, she said -- it's up to the communities to decide how to administer vaccines based on their needs.

"If you provide communities with the tools they need to protect themselves, they oftentimes are really able to do it," she said.

Because so much power has been turned over to different regions of Alaska and the health care providers trusted in those areas, health care workers have been able to "meet people where they're at," Zink said: That means they'll deliver vaccines by boat, dog sled, helicopters and small planes, or go door-to-door in small communities to vaccinate as many community members as possible.

"It's really different across the state," she said. "It's highly reliant on local communities who know their system ... way better than we (the state health department) do."

It expanded the eligibility criteria

Vaccine eligibility in Alaska is more expansive than it currently is in most other states: Vaccines are available to anyone 55 years or older, people with certain underlying conditions, essential workers, residents of a multigenerational household, anyone who assists a senior in getting vaccinated and anyone who lives in a community where 45% of houses don't have pipes or septic tanks.

Expanding who's eligible for a vaccine is another strategy that helps them vaccinate Alaska Natives and low-income residents who are disproportionately vulnerable to Covid-19.

Alaska's first round of Covid-19 vaccines is open to young people who accompany an older person to get a vaccine as well as residents of multigenerational households.

In areas where the population is mostly Alaska natives, there's a greater amount of people living in multigenerational housing. That qualifies young people who may live with an at-risk elderly person to get vaccinated, too, said Dr. Bob Onders, administrator of the Alaska Native Medical Center in Anchorage.

And since 25% of rural Alaska doesn't have running water or sewage, which can heighten residents' risk for respiratory illness, it didn't make sense to exclude rural residents from the first round of vaccinations, Onders said.

"Having more vaccines and quicker eligibility for Alaska Native people at higher risk is starting to even out the risk of Covid, cases of Covid, hospitalizations and mortality," he said.

Sovereign tribes received vaccines separate from the state

Alaska Natives have borne the brunt of Covid-19 in the state -- the Kaiser Family Foundation's Covid-19 data tracker shows that Alaska Natives make up more than a quarter of Covid-19 cases but 15% of the population, compared to White residents, who made up 38% of cases but 68% of the population.

Debra McCarty, the director of the medical clinic in Fort Yukon, Alaska, administers a COVID-19 vaccine in February. Sovereign tribes received their own vaccine allocations through the Indian Health Service.

Tribal health systems had the option to receive vaccine doses through the state or through the Indian Health Service -- Alaska's tribal health system chose the latter. This option gives the tribes more independence in distributing the vaccines as well as a specialized allotment of vaccines that takes into account the remoteness of where the tribes are located, the rate of infection among the tribe and handing the reins to providers that Alaska Native communities already trust.

"Rather than a top-down mechanism, where someone from outside of Alaska or rural Alaska is dictating how things are going, it's much more about giving them supplies," Onders said.

The state gets its doses monthly

Alaska asked the federal government to be treated "like a territory instead of state," so it would receive a monthly allocation of vaccines versus a weekly or biweekly lot. That made it easier to plan ahead and deliver vaccines "creatively," Zink said.

It can be costly to transport vaccines to some remote reaches of Alaska -- over $15,000 for one trip, in some cases, Zink said. To make vaccinations more cost-efficient, some areas that are less densely populated receive their entire vaccine allotment, which makes it possible to vaccinate entire communities in one go.

Alaska's state health department also doesn't have to handle vaccinations on its own. Alaska's 229 sovereign tribes, the US Veterans Affairs Department and the US Department of Defense each have a separate federal allocation for vaccines, which means more vaccines are being distributed in Alaska at once.

The state has done this before

The massive movement of vaccines is fairly standard for Alaska.

"We've been doing redistribution of vaccines for years," said Dr. Anne Zink, Alaska's chief medical officer. "It was pretty easy for us to stand up our existing [public health] structure."

Health care workers, like pharmacist Torrie Wolery in Ketchikan, often administer vaccines at residents' homes rather than create mass vaccination sites -- the state is too remote for large sites to be effective.

Some areas of the state are so remote that items aren't shipped directly there -- rather, they're shipped to centralized redistribution centers in population hubs throughout the state like Anchorage and Juneau. There, large allotments of vaccines can be stored and divided into the proper amount for the community they're going to so no area gets more or less than they need, Zink said -- something that wouldn't be possible if vaccines were shipped directly throughout the state.

So when it came time to distribute Covid-19 vaccines, the state benefited from years of preparation.

What the rest of the US can learn

Elaine Karmarck, director of the Center for Effective Public Management at the Brookings Institute, has studied trends in vaccination rates among the states since the vaccine rollout began. She said the gaps that once existed between states' vaccination rates are narrowing.

What works for Alaska won't work in more populous states or states with more urban hubs, and certainly every state can't get a monthly allocation of its doses, but some of its success could be replicated in other states.

Invest in protecting minority communities. Alaska expanded its eligibility for the first round of vaccines to include Alaska Natives and low-income residents of the state that are more vulnerable to Covid-19. While there's still work to do to alleviate that disproportionate risk, Onders said so far, it's working.

"If we want equitable outcomes, we have to disproportionately invest in communities at highest risk," Onders said.

Another way to alleviate that burden is to prioritize zip codes in addition to age and health status, Karmarck said. Vaccinating residents of low-income neighborhoods or areas where the majority of residents are Black, indigenous or people of color could reduce Covid-19's disproportionate impact, though backlash is likely: In Dallas, county officials axed their plan to prioritize residents in "vulnerable zip codes" after the state threatened to reduce its vaccine allocation, the Texas Tribune reported in January.

Enlist trusted members of communities to educate. In communities where residents are hesitant to get the vaccine, particularly among Black and Latino Americans, sharing information about vaccine access is crucial to address Covid-19 racial disparities, Karmarck said.

Alaska's done that, Zink and Onders said, by trusting health care workers who live and work in the communities they serve to educate residents. Zink leads daily Zoom calls with Alaskans, and she holds Q&A sessions to address disinformation about the vaccine. In Alaska Native communities, that can look like calling on young residents to inform their elders.

Customize the approach. States that were lagging in vaccinations are catching up, Karmarck said, as they formalize an approach to vaccination that best fits their state. In Massachusetts, for example, large vaccination sites have opened up at Fenway Park and Gillette Stadium to accommodate more people and storage the vaccines require. It's improved the state's vaccination rates, she said.

That approach may work in a relatively small state like Massachusetts, but the opposite is true in a state like West Virginia, which led the US when vaccines first became available by entrusting local pharmacies to vaccinate residents of the more rural parts of the state, Karmarck said.

Alaska's unique approach to vaccinations has worked because the state has always had to adapt to deliver health care services to residents. The sooner other states customize their vaccination process, the narrower the divide between states' vaccination rates will be, she said.

CORRECTION: An earlier caption on this story inaccurately described what was shown in the photo that tops this story. It has been updated to say that it shows a charter plane in Birch Creek, Alaska, preparing to take residents to receive the Covid-19 vaccine.