Aloha e Governor Ige: The way to restore Hawaii’s economy is to prevent reintroduction of the virus.

Hawaii continues to fare well in the coronavirus pandemic. This is in large part because airplane and cruise ship travel has been decreased by the 14-day quarantine order, and because residents have adhered to a prolonged and unsustainable shut-down of social and economic activity. Now we must find a way towards an economic revival that supports the people and their health.

In the 18th and 19th centuries visitors to Hawaii introduced many waves of infection that had a devastating impact on the health of the people. With that history in mind, and with our improved understanding of the science of how infections spread, we have an obligation to ensure that uncontrolled infection never again harms the people of Hawaii.

Our goal should be to eliminate COVID-19 transmission within the islands, while also taking steps to revitalize the economy and community life. As Hawaii’s economy is largely dependent on tourism, we must develop a plan to prevent the arrival of infected individuals.

If we excel at this task and keep our infection rate low, we will attract responsible visitors who wish to enjoy the benefit of travel in a beautiful and disease-free state. Such visitors will expect to encounter extra steps during their trip to ensure that Hawaii remains safe.

Specific Actions Recommended

1. The state should develop a test-based strategy for preventing importation of new cases of COVID-19 through airports. Work on this should begin immediately, as visitor numbers at present are small, and it will take weeks to stand up a system that can function at scale.
2. The visitor strategy should include pre-travel, test-based screening for air travelers to reduce the risk that they are infected with COVID-19 before interacting with the local population. Many patients are infectious before symptoms develop, and numerous studies have shown that temperature checks are ineffective as a primary means of screening. Temperature checks and symptom screening are not sufficient to protect the people of Hawaii and will miss many infected patients. Quarantine policies should be maintained and enforced for travelers from endemic areas who don’t wish to be tested.
3. Hospitality industry workers should be protected by this system, including regular access to testing and other health care services, as well as modified service protocols to protect them from travelers who test positive or refuse testing.
4. A more robust system of testing, contact tracing, isolation / quarantine, and surveillance must be grown. Expanded training of contact tracing personnel should be prioritized now, in anticipation of a summer surge in cases as tourism returns. Free, accredited training programs such as the Johns Hopkins / Bloomberg program are available and can supplement state efforts. Work can also be done at the county level by having the Department of Health authorize experienced individuals to oversee program development and expansion. This rapid growth may require assistance from outside the Department of Health. The governor should expect cooperation from the different involved elements and accountability for meeting specific metrics. This should include timely (within 24 hours) and comprehensive contact tracing of all cases. Metrics of success should be monitored and publicly available to assess the efforts and to reassure the public that the system is functional.
5. Given the low number of cases currently circulating among the local population, the state should lift stay-at-home orders and allow for increased ease of travel between islands. High standards of respiratory hygiene should be maintained, including wearing masks in crowded areas and maintaining spacing. Sick people should not be allowed to board airplanes.
6. The state should continue to coordinate with county mayors who are initiating a phased re-opening of businesses, with lower risk businesses re-opening first. The effort should be paired with disease surveillance so that people have confidence that the re-opening is occurring in a way that’s safe and sustainable. Higher risk businesses that require significant modifications to re-open should receive financial support for renovations from the county and state disaster relief funding.
7. One of the greatest risks as we open up is “super spreaders,” large transmission events linked to infected individuals and facilitated by crowded gatherings that do not follow physical distancing. Gatherings of more than ten people should continue to be restricted to limit the size of any outbreaks. Gathering-size limitations should be revisited every two weeks if case counts remain low and the state builds an effective system to prevent importation of new cases.
8. Medical practices and hospitals in Hawaii should resume routine patient care, but with elevated precautions in place to separate potential COVID-19 patients from other patients. In particular primary care and outpatient offices should continue to make use of symptoms-based screening prior to visits and enhanced use of telehealth.
9. Effective messaging to medical professionals and to the public at large should be a priority. In order to build trust, limitations in the state response so far should be acknowledged, with a plan outlined to improve performance and integration of the various state agencies. Culturally appropriate messaging should be used to reinforce concepts like crowd avoidance and respiratory hygiene with the public.
10. Mask wearing in crowded public spaces and in public transportation should be required in order to increase adherence. Hand hygiene should be readily available in all public places. Messaging around mask wearing should focus on it as a social responsibility and way of showing respect for others.

Without delay, state leadership should:

1. Create a workable plan to verify testing of airplane passengers for COVID-19 prior to travel, with appropriate quarantine provisions for those who don’t test or have 
evidence of illness.
2. Mandate the growth of testing, timely contact tracing, and quarantine services by the 
Department of Health and affiliated organizations that will work with them.
3. Establish clear protocols for voluntary placement of COVID-19 patients who cannot self-isolate at home into a quarantine facility. This includes use of specific hotels, safe cleaning criteria for those hotels to protect workers, eligibility criteria for admission, and wrap around services (e.g. medical check-ins, food delivery) for patients.
4. Increase test-based surveillance of high-risk populations and living situations. This includes health care workers, hospitality industry workers, shelters, prisons, nursing homes, and public housing.

Several hundred people in Hawaii including many doctors, nurses and other health care workers have indicated their support of this plan.