Editor’s note: Civil Beat reporters spoke with Lt. Gov. Josh Green, an emergency room physician, Thursday about the status of the rollout of COVID-19 vaccines and the possibility of a return to normalcy. Here are some highlights from the interview, which has been edited for length and clarity.

Civil Beat: We’re going to start the conversation with some questions about vaccine expectations. What are the limitations of the COVID-19 vaccines? Realistically, what can people expect to gain through vaccination in terms of their own immunity and in terms of the immunity of others around them?

Green: It’s a great question right off the bat. So the expectations that we have right now have to first revolve around how much vaccine we can get. I know this is kind of a broader question than that, but the amount of vaccine that we can get, no matter how good it is, is somewhat limited. We would love to have three, four or five times as much vaccine right now to get to all of our kupuna and all of our high risk groups. But we just can’t.

Lt. Gov. Josh Green has proposed relaxing Hawaii’s Safe Travel rules for people who have been vaccinated. Screenshot

No vaccine is perfect. The flu vaccine, for example, is usually only about 50% effective. Pfizer and Moderna, which got emergency-use authorization on Dec. 15 and Dec. 22, respectively, have been deemed about 94.5% to 95% effective to prevent cases of COVID-19 in those who have had both shots. And the shots do come three weeks apart for Pfizer and four weeks apart for Moderna. So people can be pretty well assured that if they get both shots, and then they have about two weeks for their immune system to ramp up, that they will be immune from catching COVID-19.

Now, the next question is, can they expect to not spread it? That’s called sterilization immunity. And in other words, if you get the vaccine, do you sterilize your upper respiratory area, your nose and your throat so you can’t carry so much virus that you could spread it by breathing or coughing or talking to someone up close if you don’t have a mask on? That’s not been confirmed definitively, but they do believe the viral loads will be much less. So you shouldn’t be able to spread it. And then there are other vaccines coming on that are going to have different profiles of effectiveness.

The Johnson & Johnson shots are deemed right now to be slightly less effective to stop the virus, only about 66%. But it does so far show that it decreases severe illness and fatalities.

Civil Beat: What do the coronavirus mutations that we’re hearing so much about mean for the vaccine rollout here in Hawaii? How might these new variants of the virus complicate Hawaii’s journey back to normal?

Green: They’re pretty impactful, potentially. … The vaccine will work, we believe, against all of these variants. And they’re checking that with advanced research right now as we speak. It appears, and we’ve been told this by some of the pharmaceutical companies that are making this vaccine, that it usually takes five to seven years before a mutation is so significant that it would just not respond. It would not be susceptible, I should say, to the immunization.

But they’re going to check that real carefully because we don’t want to get an outbreak of something like that B117 (found in Britain) and have it spread fast. The good news is our positivity rate in the state — that’s the percent of positive cases per day based on testing — has been dropping lower and lower and lower. As of Jan. 5, it was 3.48% across our state and as of today it dropped down to 1.9%. So the rate of positivity is dropping, dropping, dropping. We would expect that to be going up if we were loaded up with, say, that B117 variant. So I think we’re OK.

Civil Beat: How does the state assess where the demand is for vaccinations and then match that demand with the appropriate number of vaccine doses, health care workers to administer the vaccines, etc.? And as a follow up, if you could describe how the state decides to allocate vaccines to the neighbor islands in particular.

Green: Yeah, that is a really important thing to discuss, because I think it’s important that people understand that what we’re doing is analytical and meant to be fair. So let me break it down a little bit. First of all, the vaccine is being allocated state by state based on population. So Hawaii, with our 1.4 million people, are we getting an appropriate amount as per our population as compared to a bigger state? And then within our state, what we’re doing is we are doing it once again by our proportion of population. So that as well as we can, we’re trying to match the exact population with the exact amount of vaccine. For example, Big Island has 14% of our population that’s 16 years old and older. They’re receiving just under 14% of the vaccine, whereas Maui has 11% of our population that’s 16 and older. They’re getting 11% of the vaccine. And on Oahu, it’s 69% and 69%.

Josh Green, COVID-19, coronavirus, vaccine, pfizer, moderna, pandemic, shot, immunization
Lt. Gov. Josh Green administered about 50 COVID-19 vaccines to health care workers in Windward Oahu in December. Courtesy: Lieutenant Governor’s Office

Hawaii got a little bit more, just about 2% to 3% more than expected because we don’t break up the trays. The trays each have 975 doses. And we don’t like to break up the trays because you have to be careful to keep these vaccines under very low temperature. And the moment you remove them from the dry ice and begin to expose them, you run the risk of them not being effective. But we’re trying to match the population and need with exactly the amount of vaccine. There are some nuances to this. If there were a bunch of nursing homes in one region, they would get a little bit more vaccine as compared to the population because they have an even higher risk.

We have the capacity to give 80,000 shots a week. But unfortunately, the federal government really right now can only allocate 40,000 doses. In fact, the doses have been ramping up quite significantly. In our very first week we got something like under 5,000 doses. Last week we got 32,000. This week we got 40,500. So it’s ramping up, and of course it will soar up when we get extra vaccine companies approved. But right now it’s meant to be as fair as possible. It won’t be perfect. It’s the biggest public health project we’ve ever had. But we also want to make sure people understand, like, for instance, on Maui. They were worried because they pushed through their vaccines real fast. They were very efficient, but that then meant there was a little bit of a lull before they had more vaccine and it appeared to individuals that they were getting shorted. That wasn’t the case.

Civil Beat: You said you have the capacity to administer 80,000 per week, but it seems the state, while you have been ramping up recently, has been struggling to give out the doses that it has. Is that really a realistic number?

Green: Well, it’s not perfect, there’s no doubt about that, but the challenge has been this: that in the beginning when we were getting vaccine and it was a much more limited number and we didn’t know except for two and a half, three days before the next week how much you’d be getting, it was very difficult to try to schedule more people, a lot more people anticipating you might not get enough vaccine. And you still have to have some confidence that you’re going to do the second shot. So that’s a pretty complex question, actually. So let me address it even further. As of this minute, we’ve done 181,707 shots. And as of this minute, we have 227,600 doses in the state available. So that’s just under 80%. Next week we will need to do probably upwards of 40,000 second shots. So if something happened, if the system crashed, we have to have enough to sustain the steady distribution of vaccine. Now, next week or even by the end of this week, we intend to get an additional 40,200 doses, taking us up to a new total of 267,800. So we get to push ahead. But we didn’t have that assurance before.

Now we absolutely can give the shots. Another thing that was challenging maybe in the first three weeks was we didn’t have the large venue set up.

I don’t want to use this as an excuse, but it was a little chaotic switching over the presidents, and our last president, let’s just say, was less than engaged on the vaccination program. And so we had so much uncertainty that to just race ahead could have meant really catastrophe if all of a sudden things got shut down on us. So we did what was responsible, whereas some other states, their numbers look good when they raced ahead and just shot out all their vaccine. But unfortunately for them, they’re now struggling to catch up. So that’s a long way of saying we’re 80% delivered now. And as long as our supply continues, we’ll be able to at least do 50,000 shots per week and cross fingers.

Civil Beat: Speaking of the presidential administrations, both the Trump and Biden administrations have suggested that states revise their vaccine rollout to place a higher priority for people in the 65-plus age category due to risk of illness and death. Many states have updated their plans accordingly so far. Could you explain why Hawaii has not?

Green: Sure, so our top priority is kupuna and all those who care for our kupuna, and that’s the way I want people to at least understand the approach. Now, it’s been hundreds of hours of discussion about how to get enough of our 75-plus individuals and then our 65 to 74 individuals. But look at the numbers for a moment just so you can see the greater shape of the vaccination mission. Now, any state can say they’re vaccinating 70 and up, 65 and up like California, but can they actually do it? And the answer is no.

Pier 2 is the location for Hawaii Pacific Health COVID-19 vaccinations. January 18, 2021
A mass vaccination site opened last month at Pier 2. Cory Lum/Civil Beat/2021

I could have said let’s just do 65 and older. And it wouldn’t have made one darn bit of difference until we actually have the vaccine in state. But there’s a couple major considerations, which I’m glad we have an hour to talk about this because it’s really complicated calculations. OK, so you have to look at each state and see where they are. Now remember, Hawaii has the lowest rate of COVID-19 in the country by a lot. We’ve done a lot of good things. We did some stupid things early on, but we’ve done a lot of good things to date. And so we have the really low rates right now.

We’re trying our best to get extra vaccines to vulnerable populations. You can even make the case that we had the outbreaks at the prisons. We want to get the prison guards and some of the prisoners, especially the older ones, vaccinated. I know people will think that’s a controversial statement, but some of those individuals are getting vaccinated. We are all humans. We want to protect people even if they’ve made a mistake in life.

Civil Beat: What mechanisms are in place to ensure that vaccines that we do have here in Hawaii are not being wasted; have any doses been wasted so far? And if so, talk to us about why that’s happening and maybe what we could do to better prevent it?

Green: This is one problem that probably doesn’t exist for us, which is amazing because we’re capable of having all sorts of problems. There’s a lot of logistical stuff this far away from the mainland and bringing in this vaccine from far away. But we’ve been extremely good about not wasting any vaccine.

As you know, the vaccine requires extremely low temperatures. And once you draw it up into the syringe, that’s it. It’s not going back in the vial. It can’t go back into storage. We have been exclusively using appointments to get people to come in and those appointments are adhered to. Like you can’t believe, there’s really few people that are skipping out on their appointments for obvious reasons. They want to get the vaccine and they don’t want to try to get back in the line because it’s not totally easy to sign up. I mean, there hasn’t been enough availability to sign up efficiently and over and above our capacity.

At the end of the day, there are typically a handful, three, five, seven, left at the end of the clinic because you finally exhausted all the people that came and a few people just can’t get there. … We then call people that have either volunteered to be on a waiting list, which is usually very, very few, or people take down names of individuals that are also volunteering that have not yet been vaccinated. There were a lot of volunteers at our vaccination sites and if they are still there and available, they can get the vaccine if there’s some left over. That way, we waste almost nothing. Now, can I say that it’s no waste? I don’t think that would be reasonable to say, but I’ve never seen such an extreme attempt to use all of what we’ve got.

Civil Beat: Speaking of the Johnson & Johnson and AstraZeneca vaccines, can you tell us a little bit about the unique limitations of these newer vaccines or any nuances about how they’ll be used or their limitations? And then do you have a timeline or estimation of when you will be able to use these and get them here in the islands?

Green: Yes, so they do have some different profiles, I can speak mostly to the Johnson & Johnson because I have been studying that a little bit more than the others. The Johnson & Johnson (vaccine) has now been put up for emergency use authorization as of about three hours ago … I’m almost certain they will be approved in the coming days. That will be a big addition to our armament against this virus because it’s only one shot. Now, having a vaccine that’s been two shots has had a lot of the challenges that we alluded to before. Signing up is important and good tracking is important because you have to logistically be sure you get the second shot to get the real value out of the vaccine to go from 50%-95%. So you have to be a lot more on your game. With just one shot, there are far fewer limitations.

We could probably use the Johnson & Johnson several ways, one into more rural areas. I’m going to talk about the limitations in a second. Two, to individuals that might be a little bit more transient. … Now, I would never, never recommend one shot over another and not let people choose for themselves, because the Johnson & Johnson, in fairness, is a little less effective. … It does however protect against fatalities, which is really the most important thing overall in my mind as a doc.

Now, the AstraZeneca is another vaccine that’s coming, and it’s already been approved in Europe. It appears to have some interesting additional profiles. The AstraZeneca, I believe, has  already been shown to have a little bit of extra capacity to do sterilization immunity.

And so those vaccines may have a different benefit for different parts of the world. So over time, probably over three months, we’ll see some states preferring one vaccine over another, some states preferring one vaccine for a certain sub-population over another. … So, you know, I think everyone’s going to make up their own minds, and we’ll be there ready to help them through it.

Civil Beat: We had a reader question that was related to this, and you kind of touched on this, but do you foresee a situation where if a person gets a vaccine that is less effective than others, would they be able to receive a more effective vaccine later? And this question was from Karin.

Green: That’s a brilliant question. I have to admit, though I’m a doctor, my job as a virologist has fallen down. I mean, I studied that stuff a while ago. I simply don’t know yet whether they have done adequate studies to assess whether or not you can have two separate vaccines, even given an interval time. They do work with different mechanisms.

It probably will be OK. But at this point, it’s gone so fast, I don’t think anyone wants to take any risks. So each of the companies is going to be studying their vaccine. Each is going to study to see if they need a booster, particularly Johnson & Johnson, which is just one shot.

So this first year, we’re going to get good immunity. The second year we’re going to have a full understanding of how effective each vaccine was. And then in subsequent years, we’re going to find out how often you need a booster, like you get a flu shot every year.

Civil Beat: I wanted to ask you about the Safe Travels program and the possibilities of using so-called vaccine passports to bypass quarantine requirements. Do you anticipate any interisland and trans-Pacific restrictions to change?

Green: Yes, that’s the big question right now. So I can tell you what I’ve proposed to the gov and to the mayors. What I proposed is that, yes, based on vaccination status, we begin to relax some of the Safe Travels rules that we have.

We have a new option if we can demonstrate that people are immune. In other words, they’ve had both of their shots for Pfizer or Moderna and it’s been an additional two weeks that they’ve had a chance for their immune system to get up to speed. But I have proposed that first, let’s make sure it’s fine. It’s working well already with the vaccine. We’re starting to see the numbers come down. I do believe they’re connected to a degree already.

After we’ve got through the majority of 1b, which we’re really on our way (to do), and this should happen certainly by March 1, which is just a couple of weeks away, that we allow for interisland travel … that we allow for people to travel without needing the pre-test because if they’ve been vaccinated, they have immunity. So you don’t have to go through that process anymore of getting the pre-test. Then a month later, the whole state can begin to turn our attention to what will happen safely from the mainland so that as we get through 1c … mainland travelers who could demonstrate that they’ve been vaccinated, plus two weeks, could also travel to our state with an exemption.

I foresee us using companies to verify that. We’ve already been in conversations with Clear and I believe it’s called CommonPass. They would just have an app. It’s also going to help us to use more of the testing companies.

I don’t want people to be spooked, though. … When we use the word vaccination passport, people think, ‘Oh, if I don’t have it, if I refuse to get vaccinated, I’m not going be able to go anywhere.’ No. You still will be able to use the Safe Travels program.

Also, when we want to start having big gatherings and big groups, again, let’s say, where we have the Super Bowl coming up. Right. If we could have had this already in place where people were vaccinated and they could just show through this health pass or Clear app that they’ve been vaccinated, you could have had a full crowd. Now, I hate both teams in the Super Bowl, so I don’t really care that nobody is going to the Super Bowl. But if my Steelers were in the Super Bowl, you can be sure I wish I could have gone there with a vaccine record on my phone.

Civil Beat: There is concern that even if you get the vaccine, you can still be contagious, you can still transmit the virus. Now, there’s evidence that that may be slower with AstraZeneca, but we haven’t seen evidence about that with Pfizer or Moderna yet. How do you respond to that?

Green: There’s no question that there will always be some risk. We’re now going to have to, however, in my mind, balance some pretty dangerous considerations against risk for COVID-19. Hawaii has done so well. Knock wood. We’ve had, you know, like 416 fatalities, which breaks our heart. By population comparisons, we should have had 1,600 or 2,000 fatalities. The same thing goes for our case count.

But we’re still shut down and there’s so many things that people aren’t able to do. … I’m not really sure we can go another six months to a year without beginning to normalize. People are starting to forget what it is like to have normal human interaction and go about their lives.

I’m very hopeful that when we get a lot of extra vaccine that we’re able to move up the 65 to 74. Because the one thing that I want to do more than anything is to vaccinate everyone from 65 up, because I know that that is going to really relieve the pressure on society, the angst about COVID-19. As soon as we have those shots, we’ve got to move there, but I think our overall approach has been to balance everything out by the minute so that, you know, so that we don’t leave anything too much to chance.

Civil Beat: You mentioned that volunteers at some of these vaccination sites may be able to get the vaccine. Quite a few of our listeners have asked how can they volunteer?

Green: They should go to the Health Care Association or to Queens or to a church or the Department of Health through our website. There’s a Hawaii Health Corps Facebook page where we take people’s names and we put out blasts of opportunities to volunteer. It is nice to imagine more and more people engaging in this volunteer effort. Some of the people, of course, are paid professionals … But anyone with any health care expertise at all or who just really wants to be a part of it should toss their names in or volunteer through us. I don’t know how many more volunteers we need, because I’ll tell you, like I said, we already have the capacity to do about 80,000 a week and we’re only doing about 50,000. So we’re already geared up. But that could change a lot. We might need a lot more volunteers for the next three months. And I sure would love to see, especially on the neighbor islands, more help for the departments of health all across the state, the county departments. I know that they need a hand too so people should go to my Facebook and I guess my Instagram.

We’ll try to get their names into the Department of Health. But I would caution people it may be few and far between that volunteers get picked right now because they’re really regimented in their plans. I mean, they have scheduled out for weeks and weeks and weeks how many people they’re going to need. So I don’t know if your name will get called up, but certainly we want everyone to get vaccinated as soon as their turn comes up.

Civil Beat: I’ve got a question here from Beth. She asks: How are the hospitals being reimbursed for their manpower? And do you have any estimate on the average cost per dose for manpower administering each vaccine? To what extent are we using volunteers to administer doses to take the load and expense off of hospitals and have many retired health care professionals stepped in who still have their license? That’s a few questions, but they’re all related. If you could address those.

Green: So we are taking volunteers from the health care community. … The average cost of a shot is between $18-$20. Of course, you have to do two for the most part, and the administration fee is covered by the insurance companies. I don’t know what that reimbursement dollar amount is, but I do know that in order to expedite the HMSA and the other insurance companies have worked with all of the health care partners to just give them reimbursement en masse so they don’t have to fill out too much paperwork. So the average cost to vaccinate a whole state the size of ours is about $30 million. And we’ve received only about $12 million from the federal government. So extra resources, some of the National Guard, some of those costs are just going to be ultimately borne through the process of us spending money as a state.

Civil Beat: Do you have to be a resident to be vaccinated?

Green: You do, unless you’re here for more than six months in the year. I know there were a couple people that I guess snuck in or tried to get it. We really wanted to crack down on that because it doesn’t seem fair when there’s this much shortage. I will tell you that I had reports from some of my colleagues across the country that some Hawaii residents who are spending significant time in other states got vaccinated there because it’s a national program. But that’s the exception, not the norm. And so if you’re just visiting, even some of my relatives were visiting and they were old and they said, can they get vaccinated there? I just told them, ‘I’m sorry, you know, you’re not old enough and you don’t live here,’ and they didn’t love that, but they’re OK, I guess they loved me enough to not be mad.

Civil Beat: Our colleague Anita Hofschneider wrote recently about vaccine difficulties facing the hardest hit communities in Hawaii. This question is from Chloe. Are there any plans to work with organizations like Kokua Kalihi Valley, the Institute for Human Services or We Are Oceania to get any extra doses that will expire to the most vulnerable populations at the end of the day?

The Kalihi Palama Health Center in Honolulu began vaccinating patients this week. Cory Lum/Civil Beat/2020

Green: The answer is yes, except that nothing will expire. But we will use it all way, way, way before anything could expire. The vaccines are kept in deep freeze and can stay for months and months. Once they actually come out of the deep freeze, they have to be used. We do have partnerships already with We Are Oceania. One person from my office is completely embedded with them so that we can quickly navigate if there’s extra challenges. The other vulnerable populations can be given vaccine directly by the director of health if she feels that that sub-population is at risk or there’s more spread going on at any given moment. For instance, at a housing complex where a lot of people are catching COVID-19 or a lot of individuals from one group, one sub-population are living. It’s difficult to do it on the fly on any given day.

And we’re trying not to deviate too much from the already highly debated and thought-out 1a, 1b, 1c categories because that was considered at great length right in the middle of it. You know, you could easily have made a case for doing 65 and up, and if you really wanted to do the highest risk — people in institutions like prisons and nursing homes and Pacific Islanders in hotspots. But there were so many considerations and we stratified risk the best we could. To pull those out now would be to undo the strategic plan that was all really based on what the Centers for Disease Control and Prevention and the Food and Drug Administration recommended. We tried to stick as closely to that as possible while considering what the actual landscape in Hawaii is.

Civil Beat: Do you want to make any closing remarks?

Green: Well, thank you for the time. I’m happy to do it again, if that would be helpful. Maybe in a month. And we can update, I think every month we should be able to do another 200,000 shots. At least we will get incrementally safer as we go.

With the new administration, we have every expectation that we’re going to continue to get more vaccine each week. And so we will get further and further ahead of where we’ve been. I also would encourage people, please continue to wear masks, continue to socially distance, continue to wash your hands until our whole state has gotten to a place where we have herd immunity because that will keep our numbers very low and it will keep our most vulnerable people safe. The vaccine won’t be perfect and won’t be 100%. It’s going to make us a lot safer, but it won’t stop all cases of COVID. But we can do that and we can help that along by making good decisions. So thank you for understanding and I hope people will reach out to me personally if they have questions. I’ll be here for you.

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