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North Dakota has doled out the COVID-19 vaccine more efficiently than any other state. What's the secret to success?

In other parts of the country, dozens of reports have surfaced of doses going to waste because providers couldn't administer them in time under strict eligibility guidelines, but good planning, deep community ties and a few built-in advantages have spelled victory for the Peace Garden State.

Sarah Nygaard, Sanford Health's nursing clinical services leader, preps a dosage of the COVID-19 vaccine at the former Gordmans store in Fargo on Friday, Feb. 5. David Samson / The Forum
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BISMARCK — When shipments of the COVID-19 vaccine landed a few miles down the road from Nekoma, N.D., the shot immediately became the talk of the town.

Joyce Esckilsen first learned of inoculation's arrival in Cavalier County from a worker at the doctor's office. Later that day, a friend called her to chat about it. Then, another friend rang to share the exciting development.

News spreads fast "when you live out in the sticks," Esckilsen joked.

Within a few hours, the 85-year-old and her husband had signed up to get the jab, and on Jan. 14, they got their first doses at the county's public health office in Langdon. The online registration process, even with some technical difficulties, took no longer than 40 minutes, Esckilsen said.

"It was no trouble at all," Esckilsen said. "They did a fantastic job."


Esckilsen and about 750 others in the rural northeastern county have gotten their first shot — a full 20% of the population.

But in North Dakota, Cavalier County's vaccination dissemination is no aberration. The state leads the nation in efficient vaccine rollout, with nearly 93% of its allocated doses already shot into residents' arms, according to the health department . Despite having received proportionally fewer doses than a handful of other states, North Dakota ranks third in doses administered per capita, behind only Alaska and West Virginia and several strides ahead of Minnesota and South Dakota. Altogether, about 11.5% of North Dakota's population has gotten its first jab, compared to a nationwide rate of about 8.8%.

COVID-19 vaccinations are prepped for use at the former Gordmans location in Fargo. David Samson / The Forum

In other parts of the country, dozens of reports have surfaced of doses going to waste because providers couldn't give them out in time under strict eligibility guidelines, but good planning, deep community ties and a few built-in advantages have spelled victory for the Peace Garden State.

There's a long way to go on the path to herd immunity from COVID-19, but North Dakota is certainly on the right track, said state vaccination coordinator Molly Howell.

Road to the top

No single factor can explain North Dakota's prosperous vaccine rollout, but officials began sowing the seeds of success long before the drug was ever approved by the federal government.

Howell and her team gathered pharmacists, medical professionals, nursing home administrators and tribal officials in late summer to develop a plan for distributing the vaccine once it came out. Partnerships forged through those meetings and other pandemic interactions established the lines of communication used in practice, Howell said.


The group aimed to solve problems before they arose by devising strategies for hypothetical scenarios. The brainstorming sessions led the state to plan for a central Bismarck warehouse where huge shipments of doses could be split up and shipped to small towns that only required a few doses.

“We have such limited quantities of vaccine that being able to break it down and get it into rural areas was crucial," Howell said. "Otherwise, we'd have had to expect people to travel long distances to be vaccinated.”

The state also bought several ultra-cold freezers and transport coolers to store the Pfizer vaccine in the warehouse. That foresight results in an extra day for distributing the vaccine, which can make a big difference, Howell said.

In contrast with some states that have limited where the vaccine is given out, North Dakota decided to enroll any pharmacy, local health unit, hospital or clinic that wanted to administer the shot. About 400 vaccine providers are now signed on with the state.

In smaller communities, independent pharmacies have played a significant role in reaching nursing home residents, which helped North Dakota finish vaccinating that priority group quicker than most other states, Howell said.

The big-picture ideas developed during the planning period have melded well with the small details executed locally.

Cavalier County Health District Administrator Steph Welsh said the rural and close-knit nature of her area has been a major asset, with the whole county banding together to spread the word about the vaccine. Local businesses put flyers in their windows with the web link to vaccine registration, pharmacies and the grocery store added paper inserts to bags of food and medicine, and the town newspaper circulated the message to readers, Welsh said. Clergy helped less tech-savvy congregants register online.

“That’s the beauty of living somewhere small and rural — everybody looks out for each other and wants to help,” Welsh said.


A farmer wheat near a defunct Cold War missile site in Nekoma, N.D.
A farmer plants wheat in a field adjacent to the ABM installation in Nekoma, N.D. Eric Hylden / Grand Forks Herald

In urban areas, there have been other keys to the logistical triumphs of vaccine distribution.

Bismarck-Burleigh Public Health Director Renae Moch said most of the shots given by her agency are administered via a drive-thru setup at the Bismarck Event Center. Health officials developed the drive-thru process months ago to do COVID-19 testing, but the same idea lent itself to vaccination, especially with the mobility issues of many older residents who are eligible for the jab.

The agency has also recruited state contact tracers to help register residents for appointments by phone.

Welsh and Moch said the most persistent problem so far has been a lack of doses. Demand far exceeds the supply they receive from the federal government, and both officials said their agencies could easily scale up operations if more doses became available.

"People want the vaccine. They're anxious to get it," Moch said. "We've had such gracious people that have come through our vaccine clinics that have had tears because they're finally getting their vaccine, and they've been not seeing their family or going anywhere for almost a year."

Warren Larson was one of the thousands to go through a Bismarck drive-thru clinic to get his first shot. The 71-year-old cancer survivor said getting the vaccine has afforded him peace of mind, though he notes he's not easing up on mask-wearing or social distancing any time soon.

Larson said he's always been a believer in vaccines because he had friends growing up that suffered from polio, which has since been eradicated in the United States. He signed up as quickly as he could for the COVID-19 shot and said he was impressed by the ease and efficiency of the process.

Esckilsen is also playing the long game with the virus and said she won't stop donning a mask. But the upshot of herd immunity is clear to her. Once the pandemic blows over, she's got "three new great-grandbabies" in Georgia and Colorado to meet.

Patients enter the COVID-19 vaccination center at the former Gordmans location in Fargo. David Samson / The Forum

Patients enter the COVID-19 vaccination center at the former Gordmans location in Fargo. David Samson / The Forum

Jeremy Turley is a Bismarck-based reporter for Forum News Service, which provides news coverage to publications owned by Forum Communications Company.
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