Hawaii’s omicron surge is pushing case counts far higher than any other time in the pandemic, but hospitalizations are still much lower than they were compared to the peak of delta’s surge.

The state data reflects a growing consensus that omicron is far less severe than previous variants.

Hilton Raethel, who leads the Healthcare Association of Hawaii, a membership group for hospitals and health care providers, says that the state data is consistent with the omicron surge in other parts of the country.

Covid hospitalizations nearly doubled between Dec. 27 and Jan. 3, but fewer people who are infected with omicron are ending up in Hawaii’s hospitals than did those infected with delta.

Those that are in the hospitals tend to be less sick than during the delta surge. Last summer, 20% to 30% of Covid hospitalizations were filling up intensive care unit beds. That number fluctuated between 12% to 13% on Monday and Tuesday.

Medical technicians collect COVID-19 nose swab samples from people lined up in their cars, around the block, at the Blaisdell drive-through testing site in Honolulu, Monday, December 27, 2021. (Ronen Zilberman photo Civil Beat)
Hawaii has a higher per-capita Covid testing rate than many other states. Ronen Zilberman/Civil Beat/2021

If all of the Covid cases today were delta rather than omicron, “our hospitalization numbers would probably be at least twice what they are right now,” Raethel said.

But it would be a misnomer to describe omicron as “mild,” says Victoria Fan, an associate professor of health policy at the University of Hawaii who also volunteers as part of the Hawaii Pandemic Applied Modeling Workgroup.

It’s milder than delta, but “should we really be comparing (it) to the delta?” she questioned. “It’s more severe than the flu.”

Her organization released a new analysis Tuesday suggesting that Covid hospitalizations could rise to between 300 to 400 per day by next week and overwhelm the state’s hospital capacity by the end of January. The group’s predictions are based on many assumptions and factors that can change such as people’s behavior and government restrictions.

During the peak of the delta surge, Covid hospitalizations exceeded 400 per day and some hospitals suspended elective procedures to handle the influx, including cancer treatments.

Raethel said because fewer patients need ventilators than the last Covid surge, Hawaii isn’t worried about oxygen or ventilator capacity, but that omicron is so widespread that on Tuesday, at least 1,000 health care workers were unable to work because they were quarantining or isolating due to the virus. He’s hoping federal money is approved soon to help alleviate the staffing shortage.

“We fully expect that the worst of this surge in terms of hospitalizations is still in front of us,” Raethel said.

Focus On Hospitalizations

Some Covid experts say that policymakers should be focusing on hospitalizations when making decisions about how to handle Covid, something that Honolulu Mayor Rick Blangiardi has said he’s relying upon.

Along with Hawaii health care leaders, the mayor plans to announce new restrictions on large indoor events Monday morning. He previously said he would consider restrictions on gatherings once Covid hospitalizations exceeded 150 per day.

“As you get further on and the infections become less severe, it is much more relevant to focus on the hospitalizations as opposed to the total number of cases,” Anthony Fauci, who leads the National Institute of Allergy and Infectious Diseases, said earlier this week.

Hospitalizations in Hawaii actually fell to 193 on Thursday, compared with more than 200 the day before.

Raethel said he doesn’t think the dip reflects a broader trend. To him, looking at case counts in conjunction with hospitalization counts is still useful, because even though the correlation is different with omicron than with delta, it still exists.

Hilton Raethel, President and CEO of Healthcare Association of Hawaii.
Hilton Raethel, head of the Healthcare Association of Hawaii, says it’s too soon to declare a turning point in the pandemic. Cory Lum/Civil Beat/2020

Hawaii has seen unprecedented Covid case counts that have exceeded 3,000 in recent weeks. On Tuesday, Covid test positivity rates exceeded 17% statewide and 19% in Honolulu.

More than 74% of Hawaii is vaccinated against the virus, with more than 78% of Oahu residents vaccinated. But most vaccinated people in Hawaii still haven’t received their booster shots, which studies suggest make a huge difference in preventing poor outcomes from omicron in particular.

The majority of hospitalizations in Hawaii are still among the unvaccinated, but breakthrough hospitalizations have risen to 40% on certain days, Raethel said. He knows of an 82-year-old who was boostered and still ended up in the hospital in Hawaii, but added that he doesn’t know of anyone who was boostered who has landed in the intensive care unit.

Thomas Lee, an epidemiologist at the University of Hawaii who is also part of the pandemic modeling group, agrees with Fauci that focusing more on hospitalizations than case counts makes sense, since case counts can be influenced by the amount of testing that’s available.

He noted Hawaii has a higher per-capita testing rate than many other states.

But Hawaii’s relatively high testing rate may still not be enough to reflect the widespread transmission, Lee said, noting that bad weather over the past week closed testing sites and that high positivity rates suggest that official Covid counts may still be undercounts.

Can Infection Be Avoided?

Amesh Adalja, a senior scholar at the Johns Hopkins Center for Health Security, said lack of testing has been a national problem since the pandemic began in March 2020. More tests are critical to help people make good decisions about isolating and preventing spread, he said.

At this point in the pandemic, Adalja believes omicron is so transmissible that getting infected can’t be avoided.

“What can be avoided is hospitalization and death,” he said, suggesting Covid vaccinations, monoclonal antibodies and antiviral treatments will help.

Adalja said managing hospitalizations makes far more sense than shutdowns aimed at forcing case counts down.

“The virus is not going to disappear,” he said. “It’s still going to be there when you end those restrictions.”

“I think that’s been a mistake throughout this pandemic, that people somehow thought that you go in your house for a certain period of time but when you come back out the virus is gone and it magically snaps back to 2019,” he said. “Having a lockdown and banning outdoor dining is not going to change everything because it’s not a major risk for transmission.”

Sarah Kemble, state epidemiologist at the Hawaii Department of Health, could not be reached for comment on Tuesday, but the agency has advocated for imposing gathering restrictions in Honolulu particularly in nightclubs or other indoor crowded spaces with high likelihood of spread.

Hawaii has been relatively restrictive compared with other states throughout the pandemic and has one of the lowest overall Covid mortality rates in the nation at 0.9%.

Pandemic to Endemic

An oft-asked question is whether omicron could signal a shift from pandemic to endemic, which some experts describe as when the virus is no longer a threat to hospital capacity and is more similar to a common cold in terms of societal disruption.

“We are inching our way to the light at the end of the tunnel,” Lee said. “Omicron is, ironically, positively impacting that shift to endemic.”

But others aren’t so sure.

Albert Ko, a physician at the Yale School of Public Health, said new variants could emerge especially given global vaccination disparities.

“The one thing that we’ve learned throughout this and particularly with Covid is that herd immunity may be illusory. The notion that we’ll reach herd immunity and everything will stop — I’m doubtful that would happen,” Ko said.

“The end game is not going to be the elimination of Covid,” he added. “The end game is how do we mitigate really the harmful outcomes that the virus gets us.”

Raethel is hopeful this surge will be a turning point in the pandemic but thinks it’s premature to say so.

“We have learned over the last two years that there’s so much we don’t know about coronavirus and where this could go. This is unprecedented in human history and I believe it’s naive to speculate as to where we’re going to be six months from now,” he said. “We can hope for the best, but this virus continues to confound us, unfortunately.”

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