Arkansas is the US's new Delta epicenter. Its health director says 'we've done everything we can' to convince people to get vaccinated.

• Arkansas is seeing its highest spike in coronavirus cases in nearly five months.
• The spread of the Delta variant has made it a new epicenter of the US outbreak.
• But Arkansas health officials are still struggling to convince people to get vaccinated.

Few states have had a harder time vaccinating people than Arkansas.

Less than 43% of the state's population has received at least one vaccine dose, and just 34% of residents are fully vaccinated - among the lowest vaccination rates in the US. That made the state a sitting duck for the Delta variant, which is significantly more transmissible than the original virus or other variants. As Delta spreads rapidly among unvaccinated people in the US, Arkansas and its neighbor, Missouri, have become the epicenter of the US outbreak.

The maps below, from the Centers for Disease Control and Prevention, show how Arkansas' latest surge correlates with its low vaccination rate. Counties with at least 100 cases per 100,000 people (in blue) also have vaccination rates below 40% (in purple).

Arkansas reported more than 1,200 new coronavirus cases on Friday - its highest tally in nearly five months. The state's daily coronavirus cases more than doubled over the last two weeks, from around 290 to 600 cases per day, on average. Data compiled by Scripps Research's Outbreak.info tracker suggests that Delta may account for more than 80% of Arkansas' new coronavirus infections. That's among the highest shares of Delta infections in the country.

Hospitalizations have risen in the state as a result: Arkansas' average is up 42% in the last two weeks, from around 270 to 380 hospitalizations per day.

The state's health director, Dr. José Romero, blames the low vaccination rate on widespread vaccine hesitancy in rural areas.

Romero told Insider that the state's health department arranged for essential workers to get access to shots at their places of work, but demand for the service was low. Even teachers have been reluctant to get their shots, he said: At most, 45% of teachers and staff at Arkansas schools have been vaccinated.

Now, the health department is planning to return to schools and workplaces to offer the shots a second time. Officials are also hosting town halls to address residents' concerns about vaccine safety, since misinformation on social media has led people to think, falsely, that coronavirus vaccines might increase the risk of infertility.

Since May, Arkansas' government has also been offering incentives for those who get vaccinated: $20 gift certificates for the Arkansas Game and Fish Commission or $20 lottery tickets.

But if those efforts don't pan out, there's no backup plan.

"We've done everything we can," Romero said. "We've made the vaccine available. We've gone the extra mile to make it pretty much on demand if you want it. We've made testing available all around the state through various means. I don't think there's anything else that we can do at this point."

Many rural residents don't see a need to get vaccinated

Access to shots may still be a problem in Arkansas, despite the state's efforts. Rural communities are historically hard to reach through vaccination campaigns, and around 42% of Arkansas counties are rural. Research from Boston Children's Hospital suggests that several Arkansas counties qualify as "vaccine deserts," with the nearest COVID-19 vaccination site more than a 15-minute drive away.

But Romero doesn't think that's the issue.

"We really do have vaccine in every county in the state," he said. "This is the home of Walmart, and Walmart is a federal partner. I say this tongue-in-cheek: You can't swing a cat without hitting Walmart. They're everywhere and they're distributing the vaccine."

Romero said he is more concerned about how difficult it has been to convince rural residents that the coronavirus is dangerous, even with the spread of Delta.

"There is a significant population within the state that still doesn't believe this to be a major health threat," he said. "They consider themselves not at risk because they're healthy."

Even within his own health department, Romero added, there are still employees "that are not believers in the vaccine."

Arkansas has one of the highest rates of vaccine hesitancy in the country. As of June, the Department of Health and Human Services estimated that 25% of the state's population might be hesitant or unsure about getting a COVID-19 vaccine. Only three other states - Mississippi, Montana, and Wyoming - had higher hesitancy rates.

Arkansas has also struggled to get people to return for their second shots. Romero said 15% of people who had received their first dose of either Pfizer's or Moderna's vaccine hadn't gone back for their second as of two weeks ago. Romero said he thinks it's because many residents were deterred by the side effects of their first dose.

That's particularly concerning given that new research suggests partially vaccinated people are more vulnerable to symptoms from Delta. A study published Thursday in the journal Nature found that just a single dose of Pfizer's vaccine was either weakly or not at all effective against the variant.