Hawaii appears to be entering a second wave of COVID-19 infection just weeks away from when it plans to reopen to visitors.
Over the July 4th holiday weekend, the state saw more than 20 new cases reported daily for four days straight. On Monday, there were seven, and Tuesday, 41 new cases — the largest single-day spike seen in Hawaii to date.
As Aug. 1 approaches — the date when travelers with negative COVID-19 test results may bypass the state’s mandatory 14-day quarantine — some experts are wary about the state’s ability to handle the virus if it keeps up at the current rate.
Thomas Lee, an epidemiologist and professor at the University of Hawaii, said the events over the weekend are worrisome.
“With current trends of double-digit increases in cases, I am concerned that we might reach a point where contact tracing can no longer contain COVID, especially if you factor in travel,” Lee said.
But even as case outbreaks worsen in other states, Hawaii officials say the Aloha State is in good shape, banking on the health department’s ability to conduct investigations and hospitals’ wiggle room to grow. Hawaii’s geography and demographics may help too.
“We are prepared and we are able to handle the increase in the number of cases,” Gov. David Ige said at a press conference Monday. “Hawaii is well-positioned to deal with COVID-19 as we consider safely reopening our economy.”
It was inevitable that the near month-long lull in new COVID-19 cases in Hawaii would not last, local epidemiologists say.
Daily case counts have fluctuated but are approaching where they were two months ago during Hawaii’s first wave of infection. At its peak, Hawaii saw an average of 28 cases in the first week of April.
Throughout May, the curve appeared to flatten. Then in mid-June, cases began to pick up again, as certain restrictions on businesses and activities were lifted.
Last month, state health officials said most new cases were in pockets of contained clusters. But new cases this weekend marked a shift in that trend.
While many recent cases were still tied to clusters — people reported falling ill after attending family gatherings without a mask, working out at a gym, or having lunch with coworkers — Department of Health Director Bruce Anderson said Monday that a number of infections over the holiday weekend were not related to known cases or clusters, signaling more community spread.
Seventy-eight cases were confirmed over the extended holiday weekend, and while most were identified through contact tracing, many were new infections among people without any known contacts or association, according to Anderson.
“What’s troubling is that many of these were newly reported lab results of infections not associated with current cases,” he said. “This is an indication that the virus is circulating in our community, and spreading, particularly on Oahu.”
Lee, who currently serves as head COVID-19 forecaster for Hawaii’s Emergency Management Agency COVID-19 Emergency Response Team, pays close attention to five-day and seven-day averages, but said those averages are only one measure of how Hawaii is handling the virus.
Lee is part of the Hawaii Pandemic Applied Modeling Work Group, or HiPAM, a volunteer collective that is developing new models of tracking COVID-19 specifically for Hawaii that includes geography, age, contact tracing capabilities and the rate of growth of known clusters — elements not always clear from daily health department reports.
Ige and Lt. Gov. Josh Green said Monday at a press conference that Hawaii’s hospitals have adequate capacity. Only three COVID-19 patients are in intensive care, and just two are on ventilators, according to Green.
Still, Ige said he would consider extending a reopen date if things change.
“We are monitoring what happens, and obviously if we do see conditions that we feel would put the health and safety of our community at jeopardy, we will consider extending that Aug. 1 date,” Ige said.
Many states have had to step back from plans to reopen as cases surge. In Florida, infections have increased at a rapid pace, hindering the state’s ability to conduct contact tracing and making it nearly impossible to keep up.
In states such as Florida and Texas, where new cases are being reported at increasing rates, contact tracing “doesn’t do much good,” Anderson said.
“Where (contact tracing) really makes a difference is places like Hawaii, where we have a reasonable number of cases that we can respond to quickly and appropriately,” he said. “We saw a peak here of over 30 people per day for a brief period of time and we were able to manage that even with the reduced workforce we had then. We have a lot more capacity now.”
Approximately 179 investigators at the state Department of Health are currently conducting contact tracing. The DOH policy is to contact new patients within 12 hours and attempt to call the people they have had close contact with within 24 hours, he said, but the process can sometimes take days.
That capacity will continue to grow. A collaboration with the University of Hawaii means hundreds of additional contact tracers will be available to hire soon. The goal is to put as many preparations in place as possible by Aug. 1, said Dr. Sarah Park, the state epidemiologist. The department is also working more quickly thanks to a new Healthspace application.
DOH is now testing everyone, even those in quarantine. That helps the state to “uncover cases that might have been unknown otherwise,” she said.
But she emphasized, contact tracing is only part of the solution.
“We need the help of our community — that’s what’s going to get us out of this and have Hawaii continue to be at the forefront,” Park said. “If our community is not practicing safe practices, it’s like walking on sand and having the sand flow backwards. Despite everything you’re doing, you’re still losing ground.”
National statistics often place Hawaii in a good light when it comes to the number of cases, deaths and testing rates per capita.
The Harvard Global Health Institute publishes estimates of how much testing should be conducted to either mitigate or suppress outbreaks.
The Harvard model says Hawaii is exceeding the testing targets it outlines. To mitigate its outbreak, Hawaii would need to conduct a target of at least 14 tests per 100,000 people, and to suppress it outright, 23 tests per 100,000 people, but the state is currently testing a weekly average of 85 tests per 100,000, far more than Harvard’s recommendations.
As of July 2, it ranked Hawaii’s COVID-19 outbreak as “mild” relative to the Aloha State’s population of approximately 1.4 million people, according to a report by National Public Radio. To date, state officials have reported 19 deaths, which is relatively few for the state’s population compared to other states.
New data from the U.S. Census Bureau, which is calculated based on demographic and socioeconomic factors, also suggests that Hawaii and its counties are relatively low risk for COVID-19 compared with other states and counties across the country.
Some of the factors in the bureau’s Community Resilience Estimates tool included the number of low-income households, elderly population, employment status, physical crowding, lack of health insurance and preexisting health conditions.
The tool considers a community “high risk” when at least 30% of its population has three or more risk factors.
The data showed that a quarter of Hawaii residents had three or more risk factors.
Of the four counties in the state, Honolulu had the highest risk, with 26% of its population having three risk factors or more, and 66% having at least one risk factor.
The highest risk tract within Honolulu was a small, mostly industrial area near the Honolulu Harbor with a registered population of fewer than 300. Fifty-eight percent of that population were found to have three or more risk factors, the data showed.
Kauai County had the lowest portion of the population with three risk factors or more, at just 21%.
However, the census data may not be the most accurate representation of Hawaii’s socioeconomic resilience and wellbeing in the time of COVID-19, said Eugene Tian, economic research administrator at the Hawaii Department of Business, Economic Development and Tourism.
“It may not be comprehensive,” he said.
For example, it does not take into consideration some important factors, including industry-based occupation and part-time worker population, that make a big difference in Hawaii, where a large number of people rely on the tourism industry for employment.
Other factors that could have drawn a more accurate picture include the number of low wage workers and the age of unemployed workers, as many young, junior workers are the first to be let go, Tian said.
Should these factors have been considered, Hawaii may not look as “resilient” in the national data, he said.
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