COVID-19 Update

Hospitalizations, Deaths, Repeat, and Vaccine Breakthrough Infections

Through December 2021

The Section of Epidemiology, Alaska Division of Public Health

Introduction
This document is intended to provide routine updates on COVID-19 hospitalizations, deaths, repeat, and vaccine
breakthrough infections in Alaska. Hospitalization and death data are those displayed on the Alaska Cases Dashboard.
Repeat and vaccine breakthrough infections and multisystem inflammatory syndrome in children (MIS-C) statistics are
produced with additional data collected by the Section of Epidemiology (SOE). This report is not designed to track the
burden of COVID-19 on hospitals; other data sources, such as HHS Protect or facility-level statistics may be more
appropriate for those questions. Data included are not final; efforts to increase completion and ensure data quality are
ongoing and these numbers will change. Additionally, more detailed summaries and reports will be produced in the
future. Data are for cases from March 2020 through December 2021.

Hospitalizations
SOE removes hospitalizations that are not due to COVID-19; for example, asymptomatic behavioral health patients or
laboring mothers tested on admission are excluded. A total of 3,157 COVID-19 hospitalizations with a known admission
date among Alaska residents were included in this analysis (Figure 1). For people with multiple admissions, the most
severe/longer admission was counted.

Figure 1. COVID-19 hospital admissions among Alaska residents, by month of admission — March 2020 through
December 2021

500
450
400
Number of Hospitalizations

350
300
250
200
150
100
50
0

Demographics
During March 2020 through December 2021, the mean age of COVID-19 hospitalized patients was 59 years (range:
newborn to 99 years). For patients admitted in 2020, the mean age was 62 years (range: 1 month to 98 years). For

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patients admitted in 2021, the mean age was 4 years younger at 58 years (range: newborn to 99 years). Hospitalizations
by sex and race are shown in Table 1.

Table 1. Sex and race among COVID-19 hospitalized Alaska residents — March 2020 through December 2021
Statewide
Characteristic Count (%) population Rate*
N (%)
Sex
Female 1,425 (45) 375,017 (51) 380
Male 1,7322 (55) 353,886 (49) 489.4
Race
American Indian and Alaska Native (AIAN) 716 (23) 113,010 (16) 633.6
Asian 212 (7) 48,382 (7) 438.2
Black 100 (3) 26,408 (4) 378.7
Native Hawaiian and Other Pacific Islander (NHOPI) 221 (7) 11,706 (2) 1887.9
White 1,294 (41) 472,386 (65) 273.9
Other 135 (4)
Multiple 120 (4) 57,011 (8) 210.5
Unknown 359 (11)
Total 3,157 728,903 433.1
*Rate is per 100,000 people within each group.

Severity Indicators
This summary includes 2,390 hospitalizations among Alaska residents. Only hospitalization records for which both
admission and discharge date had been entered are included. This restriction allows severity indicators and length of
stay to be more adequately described but results in an undercount of total hospitalizations, especially those that
occurred more recently. Tables 2 and 3 show severity indicators by all hospitalizations and hospitalizations with a
fatality.

Table 2. COVID-19 hospitalizations (n=2,390) among Alaska residents with severity indicators — March 2020 through
December 2021
Yes No Unknown
N (%) N (%) N (%)
ICU 637 (27) 1278 (53) 475 (20)
Ventilator 323 (14) 1280 (54) 787 (32)

Table 3. COVID-19 hospitalizations with fatality (n=670), among Alaska residents with severity indicators — March
2020 through December 2021
Yes No Unknown
N (%) N (%) N (%)
ICU 240 (50) 123 (26) 113 (24)
Ventilator 238 (36) 196 (29) 236 (35)

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Length of Stay
Table 4 describes the amount of time patients stayed in the hospital. This analysis is restricted to 2,390 patients for
whom both an admission and discharge date have been entered. Patients who were admitted and discharged on the
same day were counted as one day of hospitalization. Similarly, patients who were intubated and extubated on the
same day were counted as one day of ventilation.

Table 4. Duration of COVID-19 hospital stay — March 2020 through December 2021

2020 2021
N Mean Range N Mean Range
All hospitalizations 985 9.6 days 1–124 days 1405 8.7 days 1–128 days
Non-ICU patients 593 7 days 1–124 days 685 6.6 days 1–128 days
ICU patient (total 295 14.9 days 1–75 days 342 12.3 days 1–52 days
duration of hospital stay)
ICU patient (duration of 253* 9.7 days 1–75 days 272 8.4 days 1–50 days
ICU stay)
Ventilator days 109 10.3 days 1–44 days 120 9.2 days 1–41 days
*Duration of ICU stay was not available at the time of this report for 188 patients who were known to have been in the
ICU at some point during their hospital stay.

Multisystem inflammatory syndrome in children

Twenty children hospitalized with multisystem inflammatory syndrome in children (MIS-C) have been reported to the
Alaska Section of Epidemiology since the beginning of the pandemic. MIS-C is defined by fever, laboratory evidence of
inflammation, and evidence of clinically severe illness requiring hospitalization with multisystem organ involvement. The
definition requires that the patient is <21 years of age with current or recent SARS-CoV-2 infection or exposure to a
suspected or confirmed COVID-19 case within the 4 weeks prior to the onset of symptoms and no alternative plausible
diagnoses.

Eight of the 20 children met the MIS-C case definition because of a positive antibody test, so they are not included in the
above description of SARS-CoV-2 positive hospitalized patients; the other 12 were included in analysis of that patient
population provided above because they had a positive COVID diagnostic test (e.g., PCR or antigen). Eleven of the 20
children were male. Eleven were aged 0–4 years at the time of admission, five were aged 5–10 years, and four were
aged 11–20 years. Four children had a pre-existing condition. All children were admitted to the hospital, and 10 were
admitted to an intensive care unit. None of the children have died.

Deaths
Methods
Deaths are counted as COVID-19-related in accordance with national standards and reflect the recorded date of death.
This process includes auditing death certificates to verify that COVID-19 was included as a primary or contributory cause
of death, medical records review, or provider determination that the cause of death was COVID-19 based on laboratory
testing and a consistent clinical presentation (e.g., respiratory signs and symptoms, fever or chills, and fatigue). Rates
were calculated using Alaska Department of Labor and Workforce Development population estimates and are listed per
100,000 population. Death statistics are calculated without a person-time component. This makes them more
comparable to the hospitalization numbers and to national numbers from the CDC data tracker. Cases are attributed
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geographically to their permanent residence, which may or may not correlate to location of exposure, illness, or death.
Cases are attributed to report date and deaths to date of death. All data are preliminary, subject to change, and were
congruent with public state data displays as of January 31, 2022.

Results
From January 1, 2020 – December 31, 2021, Alaska recorded 1,043 COVID-19-related deaths for a statewide death
cumulative incidence of 143.1 per 100,000 persons (Figure 2). For this same period, the US death cumulative incidence
was 248 per 100,000 persons, which was approximately 1.7-times higher than the Alaska death rate. Of these 1,043
deaths, 816 (78.2%) were known to have been hospitalized and 315 (30.2%) were admitted to an intensive care unit.

Figure 2. COVID-19 deaths and cases, by month among Alaska residents — March 2020 through December 2021
250 28000
24000
200
20000
Deaths

150

Cases
16000

100 12000
8000
50
4000
0 0
Nov

Nov
Sep

Feb

Sep
Jan
Mar
Apr
May

Aug

Dec

Mar
Apr
May

Aug

Dec
Jun
Jul

Oct
Oct

Jun
Jul
Deaths Cases

Note: Data are shown beginning in March, which was the first month in which there was a death in an Alaska resident
that was attributed to COVID-19.

Demographic characteristics
Table 5. Sex of Alaska residents with a COVID-19-related death — March 2020 through December 2021
Deaths Statewide population Deaths per 100,000
Sex N (%) N (%) population
Male 632 (60.6) 375,017 (51.4) 168.5
Female 411 (39.4) 353,886 (48.6) 116.1
AK total 1,043 728,903 143.1

Table 6. Age of Alaska residents with a COVID-19-related death — March 2020 through December 2021
Deaths Statewide population Deaths per 100,000
Age in Years N (%) N (%) population
≤19 2 (0.19) 199,809 (27.4) 1.0
20–29 18 (1.7) 98,606 (13.5) 18.3
30–39 38 (3.6) 111,831 (15.3) 34.0
40–49 70 (6.7) 85,855 (11.8) 81.5
50–59 137 (13.1) 90,703 (12.4) 151.0
60–69 241 (23.1) 85,259 (11.7) 282.7
70–79 276 (26.5) 41,509 (5.7) 664.9
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 80+ 261 (25.0) 15,331 (2.1) 1702.4
AK total 1,043 728,903 141.3

Table 7. Race of Alaska residents with a COVID-19-related death — March 2020 through December 2021
Deaths Statewide population Deaths per 100,000
Race/Ethnicity N (%) N (%) population
AIAN 276 (26.5) 113,010 (15.5) 244.2
Asian 71 (6.8) 48,382 (6.6) 146.7
Black 25 (2.4) 26,408 (3.6) 94.7
NHOPI 49 (4.7) 11,706 (1.6) 418.6
White 541 (51.9) 472,386 (64.8) 114.5
Multiple races 24 (2.3) 57,011 (7.8) 42.1
Race other/unknown 57 (5.5) n/a n/a
Hispanic (of any race) 30 (2.9) 53,202 (7.3) 56.4
Ethnicity unknown 98 (9.4) n/a n/a
AK total 1,043 728,903 143.1
n/a = not available

Vaccine Breakthrough Infections and Repeat Infections

Key Points
• COVID-19 vaccines continue to provide strong protection, especially against hospitalization and death.
• Most COVID-19 hospitalizations in Alaska might have been prevented by vaccination.
• COVID-19 cases have become more common among fully vaccinated persons than they were in the initial months
after vaccine roll-out, but fully vaccinated people continue to be less likely to have COVID-19 than people who aren’t
fully vaccinated.
• Booster doses further reduce the risk of infection and hospitalization.
• While people can be infected with SARS-CoV-2 multiple times, prior infection confers partial protection against
COVID-19. Vaccination provides additional protection in those who have been infected and is recommended
regardless of history of prior infection.

Introduction
COVID-19 vaccines were first administered in Alaska in mid-December 2020. In March 2021, all persons who lived or
worked in Alaska and were aged ≥16 years became eligible for vaccination. After the Pfizer/BioNTech vaccine was
authorized for persons aged ≥12 years, eligibility was expanded accordingly in May 2021 to anyone aged ≥12 years. In
November, vaccination was authorized for persons aged 5 to 11 years. Children in this age range who were vaccinated as
soon as eligible became fully vaccinated by early December 2021. In late September, CDC recommended a booster dose
for certain persons who received the Pfizer/BioNTech primary series. The following month, booster doses were
recommended for persons who received the Moderna or Johnson & Johnson/Janssen primary series.

Randomized clinical trials showed that COVID-19 vaccines provide strong protection against symptomatic COVID-19.
Subsequent observational studies have confirmed this finding in numerous real-world settings and have further
demonstrated that COVID-19 vaccines reduce the risk of infection with SARS-CoV-2 and greatly reduce the risk of COVID-

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19 hospitalizations and deaths.1 However, waning immunity decreases vaccine effectiveness (particularly against SARS-
CoV2 infection and mild COVID-19 disease) over time, thus necessitating booster dosing.

While reinfections with SARS-CoV-2 are known to occur, they can be difficult to diagnose due to a lack of a widely
accepted definition. Observational studies have found that prior infection with SARS-CoV-2 confers substantial partial
protection against reinfection with Delta and prior circulating variants for at least 6 months.2 The extent to which prior
infection confers protection against infection with the Omicron variant is still being investigated. There is evidence that
even in persons with a history of SARS-CoV-2 infection, vaccination provides an added layer of protection.3 During
December 2021, the Omicron variant replaced the Delta variant as the dominant circulating SARS-CoV-2 lineage in
Alaska. Consequently, estimates from December represent outcomes resulting from a combination of Delta and
Omicron cases.

Methods
A vaccine recipient is considered fully vaccinated 14 days after receiving the second dose in a two-dose series (e.g.,
Pfizer/BioNTech or Moderna) or a single dose in a one-dose series (e.g., Johnson & Johnson/Janssen). Cases of COVID-19
that occur in fully vaccinated persons are classified as “vaccine breakthrough” (VB) cases.

In late September, CDC recommended a booster dose for certain persons who received the Pfizer/BioNTech primary
series. The following month, booster doses were recommended for persons who received the Moderna or Johnson &
Johnson/Janssen primary series. It is not possible to definitively distinguish between booster doses and additional doses
in the available data. In this analysis, a third dose administered more than 180 days after completion of an mRNA
primary series, or a second dose administered more than 60 days after receiving the Janssen vaccine, was considered a
booster dose. A third dose received more than 28 days but within 180 days of completion of a primary mRNA series was
considered an additional dose if it was from the same manufacturer as the primary series. Persons who were classified
as having received an additional dose were considered eligible for a booster dose (i.e., a fourth dose) after 180 days had
elapsed following administration of the additional dose. (In early January 2022, CDC guidance was revised to focus on
maintaining “up to date” COVID-19 vaccination status. Additionally, mRNA vaccine booster recommendations were
revised to now recommend receipt of an mRNA booster dose 5 months rather than 6 months following completion of an
mRNA vaccine primary series. Both changes to guidance will be reflected in the monthly report covering January 2022
data.)

All case and hospitalizations data were obtained from the Section of Epidemiology’s case-based surveillance system.
Hospitalization and death data were identified as described above. This analysis is limited to data on Alaska residents;
vaccination status of non-residents diagnosed in Alaska cannot be consistently ascertained. All data and analyses are
preliminary and subject to change.

Cases, hospitalizations, and deaths were attributed to date of specimen collection in all analyses. This date was used
because it corresponds most closely to the definition of vaccine breakthrough. For example, if a person tested positive
12 days after completing the vaccination series, that would not be counted as a vaccine breakthrough case and,
consequently, neither would a subsequent hospitalization due to COVID-19, even if the hospitalization itself occurred 14
or more days after series completion. Hospitalizations and deaths are included in this analysis if the corresponding
specimen collection date was on or before December 31, 2021, and the hospitalization or death was documented by the
Section of Epidemiology by February 1, 2022.

VacTrAK data were linked to COVID-19 case records to determine vaccination status of cases and to estimate the
amount of person-time at risk stratified by primary series vaccination status (including vaccine manufacturer and time
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since completion of primary vaccine series), vaccine booster status (whether person was eligibility for a booster and
booster manufacturer among those who had received a booster dose), history of prior SARS-CoV-2 infection (including
time since most recent prior infection), geographic region of residence (11 behavioral health regions), calendar day
(January 16 through December 31, 2021), and age group (0–4, 5–9, 10–11, 12–14, 15–19, … 85–89, and ≥90 years). One
limitation of the VacTrAK dataset is that it does not include vaccines administered by the Department of Defense or the
Department of Veterans Affairs or doses Alaska residents may have received outside Alaska. Reports from case
investigators on the vaccination status of COVID-19 cases was used to supplement VacTrAK data. The number of persons
in each demographic group with no documented history of either SARS-CoV-2 infection or COVID-19 vaccination was
inferred by subtracting the number of persons with a history of vaccination and/or infection from 2020 Alaska
Department of Labor and Workforce Development population estimates. Cases were excluded from the analysis if the
geographic region of residence (n = 7). All 7 excluded cases were classified as unvaccinated.

COVID-19 cases are classified as reinfections if positive specimen collection occurred ≥90 days after the specimen
collection date of the prior case. Very rarely, the Section of Epidemiology may revise a classification based on health care
provider input. For this analysis, all person-time <90 days from a case’s first specimen collection date was excluded
because per the surveillance definition of reinfection used here, reinfections occur at least 90 days after a prior
infection. (Note that surveillance definitions may differ from clinical judgements; persons who develop symptoms
compatible with COVID-19 within 90 days of a prior infection are advised to consult with a health care provider.)

Age-standardized COVID-19 case and hospitalization rates were calculated by direct standardization to the Alaska
resident population aged 5 years and older using the age categories as above, except the 5–9, 10–11, 12–14, and 15–19
year age categories were combined.4 Ninety-five percent confidence intervals were calculated using gamma
distributions.5

Adjusted incidence rate ratios were calculated using the Mantel-Haenszel method.6 Estimates were adjusted for age
group, region, and calendar day.

Results
Vaccine breakthrough cases over time
Through the end of December 2021, a total of 27,831 vaccine breakthrough COVID-19 cases were documented among
Alaska residents (Table 8). An additional 4,591 cases occurred among Alaska residents who were partially vaccinated.
The incidence of COVID-19 among fully vaccinated persons has remained lower than among persons who were
unvaccinated (Figure 3), though at the end of December 2021, the relative difference in incidence rates was much less
marked. This corresponds temporally to the Omicron variant wave in Alaska.

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Table 8. Reported COVID-19 vaccine breakthrough cases by month of specimen collection among Alaska residents
aged ≥5 years — January 16, 2021, through December 31, 2021
VB cases (% of total Proportion of AK residents aged ≥5
Month Total cases monthly cases) years who were fully vaccinated*
±
January 2,175 2 (0.1) 1.1
February 3,251 46 (1.4) 5.4
March 4,376 119 (2.7) 16.9
April 4,447 206 (4.6) 28.4
May 1,717 136 (7.9) 38.9
June 882 180 (20.4) 43.1
July 4,611 1,248 (27.1) 46.4
August 14,643 4,376 (29.9) 48.0
September 22,971 7,014 (30.5) 50.0
October 21,087 7,042 (33.4) 52.1
November 10,285 3,667 (35.7) 53.8
December 8,078 3,795 (47.0) 55.7
*Mean daily estimated percentage of Alaska residents aged ≥5 years who were fully vaccinated.
±
January data are from the period January 16, 2021, through January 31, 2021. January 16, 2021 was the first date that
any Alaska residents were fully vaccinated.

Figure 3. Weekly age-adjusted per capita incidence of COVID-19 among Alaska residents aged ≥5 years by vaccination
status (fully vaccinated versus unvaccinated). Data are shown beginning the week of February 28, 2021, which was the
first week in which at least 20 vaccine breakthrough cases were documented. Incidence rate estimates from prior weeks
with very few or no VB cases are imprecise.
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Vaccine breakthrough hospitalizations over time
Among vaccine breakthrough cases with specimen collection date on or prior to December 31, 2021, 358
hospitalizations due to COVID-19 were documented (Table 9). An additional 97 hospitalizations occurred among partially
vaccinated Alaska residents.

Fully vaccinated persons were much less likely to be hospitalized due to COVID-19 than persons who were unvaccinated
(Figure 4). Based on COVID-19 cases with specimen collection dates in December and adjusted for age, region, and
calendar day, the incidence of hospitalization among persons aged ≥5 years who were not vaccinated was 16.5 times
higher (95% CI: 9.9–27.5) than the incidence among fully vaccinated persons. This point estimate is higher than the point
estimate for November (incidence rate ratio: 12.1; 95% CI: 8.3–17.8). But the confidence intervals for both estimates are
wide and overlap.

Among Alaska residents aged ≥5 years with specimen collection dates in December who were hospitalized due to
COVID-19, the median age among those who were fully vaccinated was 70.8 years, and the median age of those who
were not fully vaccinated was 63.0 years (7.8 years younger).

Table 9. Reported hospitalizations due to COVID-19 vaccine breakthrough infections, by month of specimen collection
among Alaska residents aged ≥5 years — January 16, 2021, through December 31, 2021

VB hospitalizations (% of
Total total monthly
Month hospitalizations hospitalizations)
January-March* 204 3 (1.5)
April 128 7 (5.5)
May 66 3 (4.5)
June 42 5 (11.9)
July 177 32 (18.1)
August 344 67 (19.5)
September 468 85 (18.2)
October 372 82 (22.0)
November 193 49 (25.4)
December 116 25 (21.6)
*Data are from January 16, 2021, onwards. January, February, and March data have been aggregated to protect patient
privacy.

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Figure 4. Age-adjusted incidence of hospitalization due to COVID-19 among Alaska residents aged ≥5 years by
vaccination status (unvaccinated vs. fully vaccinated), stratified by hospitalizations among COVID-19 cases with first
positive specimen collected from January–December 2021.

Vaccine breakthrough cases and hospitalizations by age

Vaccine breakthrough cases occurred during December 2021 among Alaskans of all vaccine-eligible age-groups (Table
10). The proportion of cases who were fully vaccinated increased with age, which primarily reflects the higher
vaccination coverage at higher ages. The adjusted incidence rate ratios comparing unvaccinated to fully vaccinated
persons were similar across most age groups, though somewhat higher among persons aged 65 and older. This may be
because persons aged 65 and older are most likely to have received booster doses.

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Table 10. Reported COVID-19 vaccine breakthrough cases by age group among Alaska residents and adjusted
incidence rate ratios — December 2021
Incidence rate ratio for
VB cases (% of total Proportion of AK residents unvaccinated vs. fully vaccinated
Age group Total cases cases per age group) who were fully vaccinated* (95% C.I.)+
5–11 748 45 (6.0) 6.1 1.5 (1.1–2.1)
12–19 995 451 (45.3) 45.6 1.4 (1.3–1.6)
20–34 2,575 1,206 (46.8) 53.7 1.6 (1.5–1.7)
35–49 1,879 1,022 (54.4) 62.2 1.7 (1.6–1.9)
50–64 1,287 731 (56.8) 66.5 1.9 (1.7–2.1)
65+ 594 340 (57.2) 80.2 4.7 (4–5.6)
*
Mean of the daily estimated percentage for each day in December 2021 of Alaska residents who are fully vaccinated, by
age group.
+
Incidence rate ratio for cases among unvaccinated persons versus fully vaccinated persons, adjusted for age, region, and
calendar day with 95% confidence intervals. An incidence rate ratio >1 means that unvaccinated persons were more
likely to have COVID-19 than those who are fully vaccinated.

Vaccination greatly reduced the incidence of COVID-19 hospitalizations across all age groups, though the effect appears
to be somewhat attenuated with increasing age (Table 11). Data were aggregated for July–December; younger age
categories were combined to improve statistical precision.

Table 11. Reported hospitalizations due to COVID-19 vaccine breakthrough infections and adjusted incidence rate
ratio, by age group among Alaska residents, July–December 2021

VB hospitalizations Incidence rate ratio for

(% of total Proportion of AK unvaccinated vs. fully
Total hospitalizations per residents who were fully vaccinated (95% C.I.)+
Age group hospitalizations age group) vaccinated*
5–49 462 34 (7.4) 41.8 19.5 (13.3–28.4)
50–64 484 73 (15.1) 63.0 12 (9.2–15.5)
65+ 724 233 (32.2) 76.7 9.4 (7.9–11.1)
*
Mean of the daily estimated percentage for each day in July through December 2021 of Alaska residents who are fully
vaccinated, by age group.
+
Incidence rate ratio for hospitalizations among unvaccinated persons versus fully vaccinated persons, adjusted for age,
region, and calendar day with 95% confidence intervals.

Vaccine breakthrough cases by manufacturer and time since completion of vaccine series
Among Alaska residents aged 20–64 years who had not received a booster dose, the incidence of COVID-19 during July
through December 2021 was lower among persons who were fully vaccinated with each of the three FDA-authorized or
approved vaccines compared to persons who were unvaccinated, regardless of time since vaccination. However, the
largest differences in COVID-19 case incidence rates between unvaccinated and fully vaccinated persons were observed
for the Moderna COVID-19 vaccine, followed by the Pfizer and Janssen vaccines (Figure 5). This analysis indicates that
protective immunity against COVID-19 decreases over time (in the absence of a booster vaccination).

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Figure 5. Adjusted incidence rate ratios comparing the incidence of COVID-19 during July through December 2021
among unvaccinated persons to fully vaccinated (but not boosted) persons, by vaccine manufacturer and time since
completion of the primary vaccination series. This analysis is restricted to persons aged 20–64 years. Incidence rate
ratios are adjusted for age, region, and calendar day. 95% confidence intervals are shown. The grey horizontal line
corresponds to a rate ratio of 1, which would mean that persons who were fully vaccinated and those who were
unvaccinated were equally likely to have COVID-19. All estimates and all error bars are above this line, indicating that the
incidence of COVID-19 is consistently higher in persons who are unvaccinated compared to those who are fully
vaccinated, regardless of vaccine manufacturer or time since vaccination. However, the point estimates are highest for
the Moderna vaccine and among those vaccinated more recently, suggesting that the Moderna vaccine confers stronger
protection, and that the degree of protection decreases over time.

Vaccine breakthrough cases by region

Vaccine breakthrough cases occurred in all regions of Alaska during December 2021 (Table 12). A variety of factors may
affect the proportion of vaccine breakthrough cases by behavioral health region. In communities with higher vaccination
coverage, a larger proportion of cases is expected to occur among fully vaccinated persons. Other potential factors
include the extent of prior infection in a region and differences in testing practices between regions.

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Table 12. Reported COVID-19 vaccine breakthrough cases by region among Alaska residents aged ≥5 years —
December 2021
VB cases (% of Proportion of AK residents
Total total cases per who were fully
Behavioral Health Region cases region) vaccinated*
Anchorage Municipality 3,847 1,902 (49.4) 60.0
Fairbanks North Star Borough 657 275 (41.9) 48.2
Juneau City and Borough 450 273 (60.7) 74.6
Kenai Peninsula Borough 379 130 (34.3) 46.9
Matanuska-Susitna Borough 1,110 382 (34.4) 40.0
Northwest Region 398 202 (50.8) 56.3
Other Interior Region 130 55 (42.3) 55.8
Other Southeast Region - Northern 246 133 (54.1) 72.1
Other Southeast Region - Southern 329 142 (43.2) 60.8
Southwest Region 198 108 (54.5) 65.6
Y-K Delta Region 334 193 (57.8) 67.6
*
Mean of the daily estimated percentage for each day in December 2021 of Alaska residents who are fully vaccinated, by
age group.
Booster vaccination
During December 2021, among persons aged ≥20 years who received the initial primary series of the Pfizer vaccine and
accounting for age, calendar day, and region, those who were eligible for a booster dose but had not received one had a
COVID-19 case incidence rate that was 2.1 times higher (95% CI: 1.9–2.4) than the rate among those who had received a
Pfizer booster dose at least 14 days prior. Likewise, those who had received the primary series of the Moderna vaccine
and were eligible for a booster but had not been boosted had a COVID-19 incidence rate 1.9 times higher (95% CI: 1.6–
2.2) than the rate among those who had received the Moderna booster at least 14 days prior.

Small numbers preclude precise estimates of the impact of booster doses on risk of hospitalization, but during October
through December, persons who were eligible for a booster but not boosted were hospitalized due to COVID-19 at 7.3
times (95% CI: 3.6–14.7) the rate of those who had received a booster dose at least 14 days prior.

Vaccine breakthrough deaths

Among cases in persons ≥5 years with specimen collection dates during or prior to December 2021, 141 COVID-19
deaths were documented among fully vaccinated persons and 29 were documented among partially vaccinated persons.
Among the 646 documented COVID-19 deaths with specimen collection dates during July–December 2021, 134 occurred
in fully-vaccinated persons and 23 occurred in partially-vaccinated persons. Accounting for age, calendar day, and
region, unvaccinated persons died from COVID-19 at 11.8 times the rate of fully vaccinated persons (95% CI: 9.6–14.5).
Of those 134 July–December 2021 COVID-19 deaths among fully vaccinated persons, none had received a booster dose
more than 14 days before testing positive, 2 tested positive within 14 days following receipt of a booster, and 97 were
not boosted and tested positive at least 6 months following an mRNA vaccine or 2 months following the J&J/Janssen
vaccine. These numbers may change as death certificates are completed and processed and ongoing data quality
assurance processes are implemented.

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Reinfection
A total of 3,225 SARS-CoV-2 reinfections were documented among Alaska residents since the beginning of the
pandemic; 42 persons were reinfected twice (i.e., counted as a case 3 times). During July–November 2021 among
unvaccinated persons, the incidence of COVID-19 in persons without a prior documented history of SARS-CoV-2
infection was 5.8 times higher (95% CI: 5.5–6.1) than the incidence in persons with a history of infection. But in
December 2021, the incidence of COVID-19 in persons without a prior documented history of SARS-CoV-2 infection was
only 3.6 times higher (95% CI: 3.3–4.1), suggesting that prior infection was less protective in December as Omicron
became dominant. Likewise, preliminary evidence suggests that during December 2021 among unvaccinated people,
prior infection may have been less protective against hospitalization than it had been during July through November
2021 (IRR in December: 0.19, 95% CI: 0.09, 0.43; IRR in July through November: 0.07; 95% CI: 0.04–0.11). However, the
estimate for December is imprecise and the confidence intervals overlap.

While estimated incidence rate ratios indicate a partially protective effect of prior infection regardless of time since
infection, the degree of protection appears to decline with increasing time since prior infection, and especially after 179
days (Figure 6).

Figure 6. Adjusted incidence rate ratios comparing the incidence of COVID-19 during December 2021 among
unvaccinated persons without a prior documented infection versus those with a prior documented infection, by time
since prior infection. Incidence rate ratios are adjusted for age, region, and calendar day and 95% confidence intervals
are shown. The grey horizontal line corresponds to a rate ratio of 1, which would mean that persons with and without a
prior documented history of COVID-19 were equally likely to have COVID-19. All estimates and all error bars are above
this line, indicating that the incidence of COVID-19 was consistently higher in persons without a prior documented history
of COVID-19 compared to those who previously had COVID-19.

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Reinfection and Vaccination
Of the 151,744 Alaska residents with at least one documented case of COVID-19, 39,419 became fully vaccinated after
their first infection. Among persons aged ≥5 years with a prior history of COVID-19, the incidence of COVID-19
reinfection during July–December 2021 was 19% higher among persons who were unvaccinated compared to those who
got vaccinated following their initial infection (IRR: 1.2, 95% CI: 1.1–1.3).

The number of hospitalizations and deaths due to reinfections was too small to reliably assess an effect of vaccination
following infection. Eighteen hospitalizations that occurred due to reinfection cases in July–December were in
unvaccinated persons, six were in fully vaccinated persons, and one was partially vaccinated. Of the seven COVID-19
deaths in persons with a prior infection, five were unvaccinated.

Discussion
COVID-19 vaccines continue to be our single most important tool to prevent COVID-19 cases, hospitalizations, and
deaths.

The proportion of vaccine breakthrough cases in December was higher than the proportion in November. Multiple
factors determine the proportion of documented COVID-19 cases among fully vaccinated persons, but the most likely
contributor to the increased proportion of vaccine breakthrough cases is the fact that by late December, Omicron had
become the dominant SARS-CoV-2 variant in Alaska.

COVID-19 vaccines in Alaska continue to provide effective protection against hospitalization and death. In contrast to
the pattern observed with cases, the level of protection of vaccination against hospitalization observed among Alaskans
in December was similar to or even higher than that observed in November. One explanation for this finding is that
compared to vaccine effectiveness against infection or mild illness, vaccine effectiveness against hospitalization is less
affected by the Omicron variant. The vast majority of COVID-19 hospitalizations among Alaska residents since COVID-19
vaccines became widely available could have been prevented through vaccination.

The data presented here were collected for public health surveillance purposes and may be subject to unmeasured
confounding and bias. For example, persons who were fully vaccinated and not fully vaccinated may differ in their
adherence to COVID-19 mitigation measures (e.g., mask wearing and avoiding indoor crowded spaces). Moreover, the
magnitude of these differences may vary over time. Additionally, COVID-19 cases among fully vaccinated persons may
be more likely to be detected than COVID-19 cases among persons who are not fully vaccinated (e.g., health care
workers are more likely to be vaccinated than the general population and may be more likely to get tested), which
would artificially increase the proportion of detected cases among fully vaccinated persons. Finally, infection-induced
immunity may build up in the unvaccinated population faster than in the vaccinated population (due to increased
susceptibility to infection), thereby making vaccination appear less effective over time.7

The magnitude of bias and confounding may differ across settings; consequently, direct comparisons to data from other
jurisdictions or to prospective evaluations of vaccine effectiveness are difficult. Additionally, this analysis is not a formal
evaluation of vaccine effectiveness. It does not account for differential testing rates that might occur between
vaccinated and unvaccinated people. It is biologically implausible that COVID-19 vaccines would perform differently in
Alaska compared to other parts of the United States. In fact, a recent test-negative case-control analysis using Alaska
data yielded similar results to a methodologically similar national analysis.8

Interpreting differences in COVID-19 incidence by vaccine manufacturer is challenging because persons who received
one type of COVID-19 vaccine may systematically differ from persons who received a different type. For example, the

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Pfizer vaccine was available before the Moderna vaccine and so health care workers and persons in long-term care
facilities may have been more likely to have received it. However, restricting the comparison of manufacturers to
persons aged 20–64 years should limit the extent to which bias may reflect the use of a particular vaccine in long-term
care facilities.

In light of evidence on vaccine breakthrough cases and the potential for onward transmission from breakthrough
infections, the Centers for Disease Control and Prevention (CDC) recommended on July 27, 2021 that all persons,
including fully vaccinated persons, wear a mask when in public indoor settings in locations experiencing substantial or
high levels of community transmission.9 The Advisory Committee on Immunization Practices and CDC recommend that
persons who are moderately or severely immunocompromised receive as part of their primary series a third dose of an
mRNA vaccine at least 28 days after receiving the second dose.10 As of January 4, 2022, CDC recommends a booster dose
for all persons age 18 and older who received the Pfizer primary series at least 5 months ago, the Moderna primary
series at least 6 months ago, or the Janssen vaccine at least 2 months ago.11

This analysis found that a booster dose further reduces the incidence of COVID-19 and hospitalizations due to COVID-19,
though estimates are not specific to the period the Omicron variant was dominant. But analyses from elsewhere in the
United States have found that persons who have received a COVID-19 vaccine booster are substantially better protected
against Omicron than persons who are eligible for a booster but un-boosted.12

Prior infection with SARS-CoV-2 confers substantial but incomplete protection against subsequent reinfection. COVID-19
hospitalizations and deaths have been documented among Alaska residents who previously had COVID-19. Vaccination
is safe in persons who have previously been infected and evidence from Alaska and published analyses indicate that
vaccination confers additional protection among persons with a prior history of SARS-CoV-2 infection.3 Additionally, the
evidence suggests that reinfections became more frequent during December compared to previous months. This is not
surprising, given that the Omicron variant is antigenically distinct from prior circulating variants.

This report includes some data from the Omicron wave in Alaska, but more data specific to Omicron will be available in
the next monthly report.

References
1. CDC. Science Brief: COVID-19 Vaccines and Vaccination. Available at: https://www.cdc.gov/coronavirus/2019-
ncov/science/science-briefs/fully-vaccinated-people.html
2. CDC. Science Brief: SARS-CoV-2 Infection-induced and Vaccine-induced Immunity. Available at:
https://www.cdc.gov/coronavirus/2019-ncov/science/science-briefs/vaccine-induced-immunity.html
3. Cavanaugh AM, Spicer KB, Thoroughman D, Glick C, Winter K. Reduced Risk of Reinfection with SARS-CoV-2 After
COVID-19 Vaccination — Kentucky, May–June 2021. MMWR Morb Mortal Wkly Rep. 2021;70:1081-3. Available
at: https://www.cdc.gov/mmwr/volumes/70/wr/mm7032e1.htm
4. Aragon TJ (2020). epitools: Epidemiology Tools. R package version 0.5-10.1. Available at: https://CRAN.R-
project.org/package=epitools
5. Fay MP, Feuer EJ. Confidence intervals for directly standardized rates: a method based on the gamma
distribution. Stat Med. 1997 Apr 15;16(7):791-801.
6. Greenland S, Rothman KJ. “Introduction to Stratified Analysis” in Rothman KJ, Greenland S, Lash TL, eds. Modern
Epidemiology. 3rd ed. Philadelphia: Wolters Kluwer; 2008: 258-82.

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 7. Goldstein E, Pitzer VE, O'Hagan JJ, Lipsitch M. Temporally Varying Relative Risks for Infectious Diseases:
Implications for Infectious Disease Control. Epidemiology. 2017 Jan;28(1):136-44.
8. Mooring EQ, Tompkins M, Newell K, Frank M. Effectiveness of COVID-19 Vaccine Booster Dose Against COVID-19
During the SARS-CoV-2 B.1.1.529 (Omicron) Wave — Alaska, December 2021–January 2022. State of Alaska
Epidemiology Bulletin. Feb 2, 2022. Available at: http://www.epi.alaska.gov/bulletins/docs/b2022_02.pdf
9. CDC. Interim Public Health Recommendations for Fully Vaccinated People. Available at:
https://www.cdc.gov/coronavirus/2019-ncov/vaccines/fully-vaccinated-guidance.html
10. CDC. Interim Clinical Considerations for Use of COVID-19 Vaccines Currently Authorized in the United States.
Available at: https://www.cdc.gov/vaccines/covid-19/clinical-considerations/covid-19-vaccines-us.html
11. CDC. Who Is Eligible for a COVID-19 Vaccine Booster Shot? Available at: https://www.cdc.gov/coronavirus/2019-
ncov/vaccines/booster-shot.html
12. Thompson MG, et al. Effectiveness of a third dose of mRNA vaccines against COVID-19–associated emergency
department and urgent care encounters and hospitalizations among adults during periods of Delta and Omicron
variant predominance — VISION Network, 10 States, August 2021–January 2022. MMWR 2022;71(4):139–45.

Additional Resources
• CDC. Older Adults and COVID-19. Available at: https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/older-adults.html
• CDC. Certain Medical Conditions and Risk for Severe COVID-19 Illness. Available at: https://www.cdc.gov/coronavirus/2019-ncov/need-extra-
precautions/people-with-medical-conditions.html
• CDC. Health Equity Considerations and Racial and Ethnic Minority Groups. Available at: https://www.cdc.gov/coronavirus/2019-
ncov/community/health-equity/race-ethnicity.html
• CDC. Understanding Death Data Quality: Cause of Death from Death Certificates. Available at: https://www.cdc.gov/nchs/nvss/covid-
19.htm#understanding-death-data-quality
• State of Alaska. Population Estimates. Available at: https://live.laborstats.alaska.gov/pop/
• CDC. COVID Data Tracker. Available at: https://covid.cdc.gov/covid-data-tracker/
• State of Alaska. Epidemiology Bulletins. Available at http://www.epi.alaska.gov/bulletins/
• CDC. SARS-CoV-2 Variant Classifications and Definitions. Available at: https://www.cdc.gov/coronavirus/2019-ncov/variants/variant-info.html

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