Neighbor islands, particularly Hawaii island and Maui, appear to be reaching a tipping point in virus spread and could be just weeks away from a surge similar to Oahu’s, an analysis of testing data suggests.

But doctors say limited testing capacity in those areas gives us an incomplete picture of how widespread the virus might be. If hit with a surge like the one Oahu is going through, the neighbor islands will inevitably be in worse shape because those islands have fewer resources, they also say.

“This is how it starts,” said Lt. Gov. Josh Green. “Both counties (Hawaii and Maui) are at the risk of tipping into a cautionary yellow phase of spread.”

Lt. Gov. Josh Green, a doctor on the Big Island, is concerned about the case numbers on neighbor islands. Cory Lum/Civil Beat/2020

Communities are considered to be in the yellow phase of virus spread when more than 5% of tests start coming back as positive, he said.

Johns Hopkins University says that as a rule of thumb, 5% test positivity would be considered a high rate of infection — indicating more testing should be done and that it’s not a good time to ease restrictions.

Hawaii island and Maui have been dangerously close to that figure in recent weeks, according to the research of a Kauai man who has been trying to get the attention of policymakers, doctors and news reporters in the hopes of stopping a potential surge on neighbor islands. The state health department has also expressed concern about increasing virus activity in those counties.

Steve O’Neal, a father of three who lives on the north shore of Kauai, began looking at the COVID-19 testing data because he wanted to know when the schools could reopen for his children.

He used his experience working on a disaster response team for the United Nations in Myanmar to research the data, and soon, he noticed a pattern for the neighbor islands that looked familiar — the test positivity rates were inching up slowly but surely, as it did for Oahu before suddenly, there was an explosion of new cases in late July.

“We watched it kind of simmer for a bit and just explode” for Oahu, he said. It wouldn’t take much — a super-spreader event, like a series of infections at a large gathering — to trigger a surge in cases on the neighbor islands, he thought.

O’Neal’s independent research, which was based on testing data posted on the state’s dashboard, showed that Hawaii island’s daily test positivity rate was almost at 5% on Aug. 22. When O’Neal did his analysis, the state was posting daily numbers. The dashboard now displays 3-day moving averages, which tend to skew the positivity rates lower.

“I think it’s clear we’re in trouble,” O’Neal said. He’s reached out to policymakers in the hopes that they’d help sound the alarm, including to the Kauai County Council.

Green says he’s seen the rising numbers reflected in neighbor island communities.

Maui was at 2.8% as of Aug. 22, but its rate has been fluctuating, at one point reaching 4.1% on Aug. 16.

Many of the recent cases on Maui have been associated with an elderly care facility and the island’s largest hospital. Tracy Dallarda, Maui Memorial Medical Center spokeswoman, said Friday that the hospital is currently caring for 31 hospitalized COVID-19 patients. Another 38 MMMC health care workers have tested positive and are in quarantine.

“Once we have an outbreak in a health care facility, it really decreases our ability to respond to future medical events, whether it be COVID or non-COVID related, especially because Maui Memorial is the only major health care provider on Maui,” said Thomas Lee, an assistant professor of epidemiology at the University of Hawaii Manoa and the former lead COVID-19 modeler and forecaster for Hawaii Emergency Management Agency. “All it takes is one or two asymptomatic people to have some sort of medium or large-sized cluster.”

Community transmission on Maui and Hawaii island is not at Oahu’s magnitude, but the climb in test positivity rates is concerning, Lee said.

“If I were to advise a policymaker, I’d say it’s time to ramp up messaging campaigns,” he said.

Green said although there are fewer cases on Maui and the percentage is lower there, he is equally concerned for Maui and Hawaii island because Maui only has one hospital, whereas the Big Island has more capacity. Hawaii County’s COVID-19 dashboard shows that it currently has 28 intensive care unit beds.

Kauai does so little testing that it’s hard to tell with data what could happen, but O’Neal worries that more people have the virus than currently identified.

Kauai county officials said they thought testing capacity on that island was sufficient and that there is not a high level of undetected COVID-19 cases in the community.

State health officials say they are concerned about large gatherings and specifically cited two recent large gatherings on Hawaii island — a beach gathering and a funeral that necessitated contacting more than 500 people to be tested for possible exposure.

Meanwhile, county mayors have not announced any new restrictive measures, though Maui Mayor Michael Victorino said at a briefing Thursday that he would consider them if COVID-19 cases were to increase in his county.

“I feel very comfortable that what we’re doing at this juncture is very sufficient,” he said. “If anything else needs to be done or we need to step back, we would definitely do that.”

Hawaii County Mayor Harry Kim did not respond to requests for comment.

Sarah Blane, a spokeswoman for Kauai Mayor Derek Kawakami, said in an emailed statement that while Kawakami has no immediate plans for further restrictions, he recognizes that it’s a fluid situation and the incident management team is ready to respond to any surge in cases.

Green said his recommendation was for county mayors to take additional precautions — though perhaps not a full shutdown — to avoid a surge like Oahu is experiencing. “Nobody wants to experience that, believe me,” he said. He did not specify what other precautions he thought Kauai should take.

He also said he did not believe that there was enough testing being done on the neighbor islands, adding that he had been calling for 10,000 tests to be conducted daily on each island. There should be aggressive testing and contact tracing, as well as mask-wearing and social distancing, he added.

“That’s your best weapon to contain the virus,” he said.

Source: Hawaii Department of Health | The dashboard now only shows 3-day moving average figures for the chart and the 7-day average percent positive rate, which are not necessarily indicative of the daily realities of the virus.

In the past week, there was a daily average of 2,424 tests conducted statewide. Civil Beat requested the breakdowns for each county from the Department of Health, but it did not respond to the request.

The 3-day moving average of tests for Hawaii County as of Aug. 27 was 228, with 221 returning negative. It was 279 with 275 returning negative for Maui, and 31 with all negatives for Kauai.

Impact May Be Harder

Fewer resources, especially medical personnel, mean neighbor islands reach a “tipping point” much more quickly than Oahu, says Dr. Stephanie Yan, a private surgeon on Maui who volunteers for the COVID-19 Testing Coalition on Maui.

With approximately 142 people with COVID-19 being monitored by state health officials on Maui as of Thursday, Yan says the impact on local hospital staffing is already palpable.

“We’re already having issues with transferring patients to a higher level of care because Oahu is full,” she said, noting that it’s much harder to hire surge staffing amid a global pandemic, when mainland companies offer better salaries to the types of traveling nurses and specialists in need.

Yan said she believes Maui needs more testing, especially population surveillance testing. Yan sits on the volunteer doctor-led Maui COVID-19 Testing Coalition, which submitted recommendations to Maui county officials about which FDA-approved testing machines would be best to purchase with CARES Act funding to increase testing capacity on Maui.

She said it seemed like a “slam dunk” way to spend CARES Act money, but burdensome bureaucratic processes caused delays and testing machines disappeared quickly amid mainland competition.

Maui Memorial Medical Center works with Clinical Labs of Hawaii on campus and can conduct as many as 1,000 tests within the hospital, according to MMMC spokeswoman Tracy Dallarda. The hospital does not conduct community testing, she said.

State records show only about 200 to 400 tests have been conducted daily on Maui in August.

Lessons From Oahu

It’s impossible to pinpoint when community spread of the disease surpassed the state’s ability to control it, said Lee, the UH epidemiologist. Hawaii may never see as few cases as it did in May, just by COVID-19’s highly infectious nature, he said.

Source: Hawaii Department of Health

It’s also unclear what exactly made Oahu reach — and pass — a tipping point. “I wish I could tell you,” he said.

“There were too many factors that contributed to it, like the false sense of contact tracing capabilities that were limited at the time, quarantine capabilities, testing turnaround and capacity, and public adherence is a big one,” he said. “You factor all of that together and it’s impossible to quantify what the tipping point is.”

Oahu’s case surge really started to speed up at the end of July after restrictions, including restaurant and bar closures, began to ease. Mobility data showed citizens moving about much more.


Help power our public service journalism

As a local newsroom, Civil Beat has a unique public service role in times of crisis.

That’s why we’re committed to a paywall-free website and subscription-free content, so we can get vital information out to everyone, from all communities.

We are deploying a significant amount of our resources to covering the Maui fires, and your support ensures that we can pivot when these types of emergencies arise.

Make a gift to Civil Beat today and help power our nonprofit newsroom.

About the Authors