Every weekday, the Hawaii Department of Health updates its Covid-19 data dashboard indicating what percentage of the state’s population has tested positive for the coronavirus.

It’s a critical piece of information that policymakers and the public have relied upon to understand how widespread the virus is that has killed hundreds of thousands of Americans.

But at some point, the state will likely stop counting how many people have Covid each day, says Thomas Lee, an assistant professor of epidemiology at the University of Hawaii.

The virus will continue to circulate, but its presence will no longer be an emergency. Like the flu, the virus may hospitalize and kill some people each year but not at the high rates of the past 19 months.

To Lee, that day may not be far off.

“I already think we are easing into this phase of it being endemic in Hawaii,” said Lee, citing the state’s high vaccination rate and improved Covid treatment.

Molokai General Hospital sign reads ‘Don’t wait Vaccinate’.
Molokai General Hospital officials urge patients to get vaccinated right away. Cory Lum/Civil Beat/2021

Hawaii is just two months out from its worst Covid-19 surge that took hundreds of lives. At its peak, Hawaii reported more than 1,000 cases per day and more than 50 deaths per week. Correction: An earlier version of this story said Hawaii reported more than 50 deaths per day at its peak.

The delta surge came after more than a year during which Hawaii had relatively few Covid cases per capita compared to other U.S. states. For the first half of 2021, Hawaii reported fewer than 200 new cases a day, often reporting fewer than 100 out of a population of more than 1.4 million.

Then the delta variant took off in July, stressing the state’s health care systems and prompting political leaders to re-impose Covid restrictions.

Two months later, the situation has drastically improved.

“We have a reasonably high confidence that we are through the worst of this pandemic,” said Hilton Raethel, head of the Healthcare Association of Hawaii, a membership organization for the state’s hospitals and health care providers.

“As to exactly when it becomes endemic, it’s endemic now in that it’s manageable,” Raethel continued. “From a health care perspective we are out of it.”

Still, Raethel said Hawaii’s dependence on tourism means the Safe Travels program that checks visitors for vaccination cards and Covid test results could remain important for years. He thinks “true endemicity” may not come until the daily Covid hospitalizations are below 50 per day. That number was 81 on Saturday.

There’s no single definition for when a virus becomes endemic, but compared to many other states and countries, Hawaii has a head start.

More than 71% of Hawaii’s population is vaccinated, and more than 80% has gotten at least one shot. Federal officials just approved Covid shots for children aged 5-11. Boosters are now available for people who have risky occupations, are elderly or immunocompromised. The statewide virus positivity rate hovers around 2%, and the state had an average of nearly 119 cases per day over the past week.

“We have a reasonably high confidence that we are through the worst of this pandemic.” — Hilton Raethel

Gov. David Ige and Honolulu Mayor Rick Blangiardi last week loosened restrictions on large gatherings, allowing increased attendance at sporting events and weddings.

Still, state epidemiologist Sarah Kemble cautions against relaxing too quickly about Covid.

“The term pandemic really means that it’s a state of crisis. The concept of the disease becoming endemic means that the disease has become part of everyday life,” she said.

To her, Hawaii is not there yet.

“We can fully expect to see more surge waves to come,” she said.

While Raethel says fewer than 50 hospitalizations a day would be ideal, Kemble thinks more than 40 hospitalizations a day is a problem.

Part of that is her concern about hospital capacity, which is more conservative than Raethel’s. Another aspect is that higher Covid hospitalizations are correlated with higher death rates.

“How much are we willing to let this virus take lives in our community?” she asked. “What is an unacceptable burden of death?”

Even with lower daily counts, the virus continues to be lethal and disproportionately affect Pacific Islanders, including Native Hawaiians, and Filipinos. On Sunday, Hawaii reported 10 new Covid deaths.

No Single Metric

Kemble says health officials have landed on 100 cases per day as a metric for when things can go back to normal in Hawaii, but said it isn’t a hard and fast rule.

“It’s hard to put an absolute case number that is going to be ‘normal,’” Kemble said. “We have sort of settled on this number above which we are in damage control mode … to some degree all of these numbers are a little bit arbitrary.”

Anna O’Briens pub closed during the pandemic in 2020 as restrictions put in place by state and city officials reduced its business. Cory Lum/Civil Beat/2020

Raethel described shooting for fewer than 50 hospitalizations a day as arbitrary as well.

“You’ve got to pick something so you have a target,” he said. He explained the idea is that fewer than 100 hospitalizations a day is manageable, but a hurricane or another crisis would further stress the health care system so he cut that number in half.

“Less than 50 patients a day means a low positivity rate, low death rate,” he said. “That’s a critical function of the health in the community.”

One current challenge is that Hawaii hospitals are still relatively full of patients, with about 2,200 per day compared with less than 2,000 in 2019. And today’s patients tend to be sicker than normal in part because many people delayed health care during the early stages of the pandemic.

Hawaii still has about 300 health care professionals that FEMA brought in from the mainland when the delta surge was worsening. But even after they leave, Raethel thinks up to 100 people hospitalized per day with Covid is doable.

“Our hospitals are doing fine. They’re busy, but they’re fine,” he said.

Kemble, however, is worried the balance Hawaii has struck now in terms of caseloads could easily be tipped back into a crisis. During the most recent delta surge, Hawaii had to send tankers by ship to California to bring back oxygen to help oxygen-deprived patients.

She’s still being cautious with her family, wearing a mask every time she leaves her house. She sometimes eats at outdoor restaurants with fully vaccinated adults. She believes the number of cases would shoot up if Hawaii lifted its indoor mask mandate.

“Our system has taken a hit that we haven’t recovered from yet,” Kemble said. She doesn’t know how much of the population needs to be vaccinated to avoid big virus spikes, but cites 90% or 95% as possible targets.

Gov. David Ige and other Hawaii officials previously cited a 70% vaccination rate as the target for when Covid restrictions could be lifted but have since said that was too low.

A 90% or 95% vaccination rate could be challenging to reach given resistance to Covid vaccines among 9-12% of Hawaii’s adult population, according to some surveys.

‘Weird Equilibrium’

Robert Wachter, a physician and professor who chairs the Department of Medicine at the University of California at San Francisco, says compared to other states, Hawaii’s caution regarding Covid has saved lives.

But he thinks the U.S. may have reached a “weird equilibrium” where barring a new variant or a cure for Covid, immunity from the virus won’t change significantly.

As children get vaccinated, immunity may wane in adults who got the shot several months ago, he said.

“It’s just not going to get that much better than it is now,” Wachter said.

A year ago, Wachter held off on doing things like visiting his parents because he wanted to wait until things got safer. Now, he’s not waiting to do things that he wants to do because he doesn’t think the situation will be much safer next year.

He feels comfortable doing so because he’s vaccinated with a booster and he lives in a place with a high vaccination rate and low case rate.

“For things that are really important to me I’m making slightly riskier choices,” he said, such as going to concerts, restaurants and movie theaters.

Wachter still thinks vaccine requirements for indoor spaces are important and that better vaccine authentication would help. But he says outdoor mask mandates aren’t necessary in places with high vaccination rates and low case rates.

Regardless of policies, he said individuals may always make different yet equally rational choices depending on their own risk tolerance.

To Wachter, it’s when the virus reaches a point where there are about five cases per 100,000 people per day and test positivity rates of less than 1%. Hawaii is not quite there but is close.

“It’s just not going to get that much better than it is now.” — Robert Wachter, University of California San Francisco’s Department of Medicine chair

Monica Gandhi, a physician and professor at the University of California San Francisco who specializes in infectious diseases, says Hawaii’s current vaccination rate and hospitalization rate meet her criteria for indicating the virus is endemic: 10 hospitalizations per 100,000 people plus a vaccination rate of over 80% of eligible people.

She pointed to Denmark and Norway as examples of countries where political leaders looked at high vaccination rates and decided to lift restrictions because they believed the virus was endemic.

“When will we accept that or decide that in the U.S.?” she said. “I have no idea because we are extremely political here and some of these decisions are not being made rationally.”

To some extent, she said accepting the virus as a part of the new normal is a philosophical decision.

Lee from the University of Hawaii said that Hawaii’s role as a tourism destination adds a level of risk that new cases or strains of the virus could slip in.

“Just looking locally, yeah it’s pretty much endemic,” Lee said. But the fact that so many people come in and out of Hawaii constantly ups the risk of another Covid outbreak, he said. “We’re never going to be able to wipe it out purely because we will be having thousands of people coming in every day and every week.”

Regardless of what happens with the virus, or how low case counts go, Lee hopes that Hawaii residents continue to take personal responsibility for preventing the spread of disease and wear face masks when they feel sick as many people do in Asia.

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