ife at the far end of the supply chain can be a challenge even during normal times, as anyone who has ever encountered wilted lettuce at the grocery store when a barge fails to arrive on time knows. It is particularly challenging during a pandemic when even major population centers struggled to acquire essential supplies.

But despite the challenges of geography and a global health crisis, Alaska performed well in a key pandemic response indicator this spring—the state’s ability to acquire and administer coronavirus tests.

According to reference website Worldometer, which compares official state and national statistics, Alaska ranked 11th among US states in per capita testing as of mid-May, when infections from the 49th State’s first encounter with the novel coronavirus ebbed and businesses started to slowly reopen.

Alaska’s testing success in the first months of the pandemic involved considerable cooperation between medical providers—something that was already in place well before the pandemic—as well as a certain degree of creative problem-solving.

Medical laboratories and clinics in Alaska routinely tested tens of thousands of samples every year for infectious diseases before COVID-19. The Alaska State Virology Lab in Fairbanks alone analyzes about 5,000 samples a year for influenza and Respiratory Syncytial Virus (RSV), says Clinton Bennett, communications director for the Alaska Department of Health and Human Services.

Machines that process viral samples are found at public health laboratories and in hospitals and medical clinics in hub communities around Alaska.

COVID-19 testing uses existing virus testing infrastructure and also requires a test kit that is specific to the virus.

The availability of coronavirus testing rolled out in three waves in Alaska. The first public health lab test was performed March 2 at a state lab, and Alaska’s public health lab testing started to ramp up in mid-March, according to Alaska Department of Health and Human Services data.

Commercial laboratories entered the picture by late March; labs like LabCorp and Quest Diagnostics became Alaska’s main source of coronavirus test sample analysis.

A third category of testing—hospital and medical clinic laboratories—started processing large numbers of samples in early April, and testing capacity grew rapidly at these facilities.

Alaska’s geography and the relatively late arrival of the virus in the state gave the medical community a bit more time to prepare for the virus than some of the early hot spots in the Lower 48. But limited availability of materials constrained testing capacity in the first months of the pandemic and dictated the guidelines for who should be tested.

The coronavirus testing criteria were challenged when a COVID-19 case was discovered among a vulnerable population at the Denali Center, a long-term care facility on the Fairbanks Memorial Hospital campus.

Lab testing used to be something that “happens in the background” at the largest hospital and medical clinic in Alaska’s Interior, says Dr. Angelique Ramirez, medical director of quality for Foundation Health Partners, the hospital’s locally-owned parent organization.

“In a normal year, the doctor’s job is just to write the order for the test,” she says. “This year we have learned a lot more about tests.”

This spring was an abrupt education for Ramirez, who started her job at Foundation Health Partners in January.

On March 27 Ramirez received news that a resident at the ninety-bed Denali Center had tested positive for the novel coronavirus.

“We were all here very late at night, going through everything that was happening at the Denali Center and working with state epidemiology in terms of what we could do,” she says.

At the time only 129 COVID-19 cases had been verified across Alaska. The official state guidelines then were not to test asymptomatic patients to conserve the state’s limited test supplies.

But the rules for testing remained in flux, and a team of administrators and physicians at Foundation Health Partners recognized the particularly strong danger of a contagious disease outbreak in a home with dozens of vulnerable people, Ramirez explains. A federal Center for Disease Control report had recently come out detailing the way the virus spread at the Life Care Center in Washington State, one of the earliest outbreaks in the United States.

As Foundation Health Partners considered options, its leaders chose the most aggressive response available, says Ramirez.

Working alongside state epidemiologists, they decided to test each of the 73 Denali Center residents and all 135 staff members.

“It was something we came to jointly. We were all very concerned about the risk,” Ramirez says.

The round of testing revealed four cases among Denali Center staff and two additional cases among residents. Another staff member was found to have the virus from an earlier test that hadn’t yet returned results when mass testing started.

Meanwhile, a long-term care facility that usually prides itself on its airy open spaces went into lockdown, with residents confined to their rooms and treated by staff wearing full protective equipment.

A month later, the facility was able to celebrate a measure of victory. By May 1, the hospital and long term care facility were declared “COVID free” after twenty days passed without any new positive tests. No Denali Center residents died from the disease in the initial outbreak, a starkly different outcome from that of Washington’s Life Care Center.

As supplies for key equipment ran low this spring, local producers of in-demand items emerged from unexpected corners of Alaska. Distillers switched from producing liquor to hand sanitizer, and a cottage industry of face covering producers emerged.

A few manufacturers have been able to help with some of the specialized equipment needed for coronavirus testing.

The first step in conducting a coronavirus test is collecting a sample from the back of a patient’s throat. This requires a swab, a tool that looks like a long Q-tip. Swabs have been in short supply since the pandemic started. To help secure Alaska’s supply, Governor Michael Dunleavy called on Palmer business TriJet Services to look into producing additional swabs. TriJet is a custom fabrication business that usually makes parts for the aviation, construction, and other industries. The business adjusted its industrial 3D printer to make swabs that fulfilled state requirements.

After a sample is collected, the swab is put in a vial containing a liquid called a “viral transport medium.” While viruses excel at hijacking human bodies to produce more copies of themselves, they disintegrate rapidly outside of the body. The viral transport medium keeps viruses intact between the time a sample is taken and when it is analyzed. As viral transport media became difficult to acquire, the state public health lab in Fairbanks stepped up to produce a surplus that was made available to other laboratories in Alaska. This lab—the Alaska State Virology Laboratory on the UAF campus—produced more than 16,000 vials of viral transport medium between late March and late May for use by Alaska labs, says Bennett.

Alaska’s laboratories operate different brands of machines for analyzing samples; in general these machines work by amplifying the genetic material in a sample to make it easier to detect. A special chemical test kit then reacts (or fails to react) with the solution based on whether it contains the coronavirus genetic material or not.

The test kits are unique to each virus and machine used to test it. Coronavirus test kits are not made in Alaska, and their availability has been a particularly stubborn bottleneck to testing.

For example, Alaska’s largest hospitals, Providence Alaska Medical Center and Alaska Regional Hospital, both use GeneXpert machines from manufacturer Cepheid, which can return test results in less than an hour.

Both hospitals received Cepheid COVID-19 test kits in mid-April, allowing them to analyze samples in-house. But because of the limited number of test kits, the hospitals had to reserve them for high-priority patients, such as people who arrived at the emergency room with COVID-19 symptoms. Other tests went to the state lab or private labs that have longer turnaround times.

Fairbanks Memorial Hospital also uses a Cepheid GeneXpert and received an initial batch of 150 test kits in early May.

A potentially important virus testing tool for rural Alaska is the ID NOW machine from Abbott Laboratories. ID NOW is more portable than other machines—about the size of a toaster—and produces test results in thirteen minutes. In April, the Alaska Native Tribal Health Consortium announced the organization received 40 ID NOW devices from Abbott, along with 2,400 COVID-19 test kits. The supplies were distributed to tribal health nonprofit organizations around Alaska.

Providence Alaska Medical Center has five ID NOW machines, which were distributed at the medical center’s urgent care offices in Anchorage and Eagle River. Providence decided to move one machine to the hospital this spring to take advantage of its particularly fast test results.

Communities around Alaska used drive-up testing clinics to quickly and safely obtain patient samples. Drive-through coronavirus testing began March 16 in Anchorage at a temporary facility set up using resources from Providence Alaska Medical Center, Alaska Regional Hospital, the Alaska Native Medical Center, and the Anchorage Neighborhood Health Center.

Cooperation between medical clinics is by no means a unique circumstance of the COVID-19 pandemic. The different Anchorage facilities frequently collaborate and have standing agreements about how they will assist each other in the event of emergencies, whether earthquakes, pandemics, or broken pipes, says Dr. Michael Bernstein, chief medical officer at Providence Hospital.

At Alaska Regional Hospital, COO Jennifer Opsut says collaboration between hospitals was the norm in Alaska before COVID-19 but that the crisis has intensified the connections between facility leaders.

“This Anchorage community has an amazing partnership between the healthcare executives,” she says. “I’m not from Alaska; I’ve lived in other states, and we truly have something wonderful going on here.”

In April, for example, Alaska Regional needed more viral transport medium and received some from the Alaska Native Medical Center. In return, Alaska Regional was able to help the Alaska Native Medical Center with a supply of hand sanitizer.

Alaska’s goals for testing for the remainder of the year were still being developed as of May when this article was written.

When Alaska’s testing plan is finalized, it will be based on the CDC’s Division of Population Health guidelines, says Bennett. These guidelines expand testing criteria to asymptomatic populations including people who work in healthcare, places where large numbers of people live in close quarters, and—perhaps especially relevant to Alaska—people who are traveling to remote areas after being in places where the virus is circulating.

For the foreseeable future, testing efforts are focused on the style of test that looks for the presence of the virus in the body. This is due to lingering uncertainties surrounding a second style of test that detects whether people were previously exposed to the virus and have developed antibodies.

“There is still much to be learned about whether the antibodies detected provide true protection and the long-term persistence of these antibodies,” Bennett says.

At Fairbanks Memorial Hospital, Ramirez looks forward to the day when same-day coronavirus screening is widely available, so testing can again be a background part of operating a hospital.