How to Control Hawaii’s Coronavirus

Epidemic and Bring Back the Economy:

The Next Steps

APRIL 3, 2020

1UHERO Brief | UHERO

By Sumner La Croix and Tim Brown

I. INTRODUCTION

In our rst policy brief (uhero.hawaii.edu, 25 March 2020), we sketched out a possible plan for control

of the novel coronavirus in Hawaii. The plan is loosely based on the successful responses to date in places

Our main goals in this report are to review how the state has implemented steps 1 and 2 and to esh

out steps 3 and 4 more fully. We spell out in more detail how increased testing, comprehensive historical

contact tracing, and isolation of exposed and infected individuals can lead to a rapid reduction in new

infections and hospitalizations. Once this system has been put in place and has operated successfully for

several weeks, we may begin to approach several measurable targets—number of new infections, number

of new hospitalizations, capacity of the health care system to treat newly infected or exposed individuals—

that would enable Governor Ige to gradually relax his stay-at-home order and for individuals to gradually

relax some social distancing restrictions.

II. HAWAII HAS ALREADY TAKEN TWO BIG STEPS

Hawaii has three circumstances that facilitate effective implementation of a coronavirus control plan:

The rst step in implementing an effective coronavirus control plan in Hawaii was to restrict travel

between Hawaii and overseas destinations and between each of the Hawaiian islands. This has largely

been accomplished. Passenger arrivals on international ights began a steep decline on March 1 while

arrivals on domestic ights did not begin their steep decline until March 13. By March 22/23, international

and domestic arrivals had each fallen by 80-90 percent. As residents became increasingly aware that

most people testing positive for the coronavirus had been infected while on overseas/mainland travel,

pressure grew for the state government to restrict this travel more tightly. On 23 March 2020, Governor

Ige imposed a mandatory 14-day quarantine on all incoming visitors and returning residents from the

U.S. mainland and foreign countries. One week later (March 30), Governor Ige imposed a mandatory 14-

day quarantine on virtually all interisland travelers, including Hawaii residents, that began on April 1. The

The quarantine on overseas and mainland travel has contributed to a further decline in daily tourism

arrivals at Hawaii airports, from roughly 2,000 people on March 25 to just 121 people on March 30. However,

even this level of arrivals places additional burden on public health ofcials and resources in the state and

counties, leading Honolulu Mayor Caldwell to ask President Trump to prohibit all nonessential travel to

Hawaii. We expect the number of arrivals to decline further as more potential visitors become aware of the

14-day quarantine, the stay-at-home restrictions that apply to visitors after their quarantine period, the

closure of virtually all indoor and outdoor tourist destinations, and the rapidly shrinking daily schedule of

ights to and from the Islands.

The state has taken a number of measures to monitor and enforce the travel quarantine. If there are

signicant violations, monitoring and enforcement measures could be tightened. Current efforts are already

an option if signicant tourism ows continue from particular cities/countries. Another option to further

restrict discretionary travel is for the state to request that airlines and travel booking agencies and websites

inform all potential travelers about the state and interisland quarantines prior to travelers booking their

itineraries.

Reducing travel to very low levels is important for control of this epidemic because it allows all parties

in Hawaii—governments, organizations, individuals, and households—to focus on controlling community

transmission. Tracking of Hawaii cases shows community transmission to be a source of 12% of 186 cases

classied as travel or community acquired through March 31

, but another 26% of these cases are residents

whose source of exposure remains unknown. Community transmission is clearly underway in the Islands.

contact tracing.

The second step in implementing an effective coronavirus control plan in Hawaii was for county mayors

and the governor to order all residents and visitors to stay at home and to take social distancing measures

when in public places. Such measures, if implemented effectively, can radically reduce community

transmission. Between March 4 and March 25, the four county mayors imposed a variety of restrictive

orders and voluntary recommendations that varied enormously across the four counties. On March 25,

2020, Governor Ige moved to standardize restrictive measures across the state by imposing a state-wide

order to stay at home and to engage in social distancing. The measures were instituted to help achieve

two goals: (1) to slow transmission of the virus between individuals and (2) to reduce the burden on the

state’s health care providers that would result if there were to be a big surge of very ill individuals requiring

private yards look increasingly deserted, with most people in nonessential jobs staying home and observing

Violations of social distancing have also been observed in grocery stores and in lines outside grocery

stores. Long lines of people have been seen outside some grocery stores on Oahu thirty minutes prior to

opening. Customers have commented on a lack of social distancing near the check-out areas. Behavioral

economics teaches us that “small nudges” can lead to big changes in consumer behavior. Simply putting

marks six feet on the oor near grocery checkout stations can remind people to observe social distancing.

We urge that these businesses take measures, including small nudges, to ensure that it is possible for

customers inside and outside the store to maintain social distancing. Limiting the number of people in the

store, placing distance markers on store oors, and taking on-line appointments for times to enter the

long lines at store opening.

Strong warnings against such behavior are preferable to heavy-handed enforcement, as it is critical for

government to maintain the trust of citizens during a time when its decisions impose such substantial costs

on people. Much more needs to be done to educate people how social distancing measures benet a broad

publicize the gains from staying at home and social distancing both to the person taking these actions and

to others in the community, including the elderly, health workers, and people with compromised immune

systems. Professionally produced and informative commercials, social media messaging and news stories

could highlight the possibility of asymptomatic transmission locally, make clear that the coronavirus is

circulating in our community, and build a sense of social solidarity in protecting our communities, especially

positive after a funeral in Albany, Georgia; the 46 choir members who tested positive after a 60-person

choir practice in Mount Vernon, Washington; the 25 of 50 guests who tested positive after a 40

party in Westport, Connecticut; and the 80 people who tested positive days after a conference at the bio-

tech rm Biogen in Cambridge, Massachusetts. Reporting local clusters and what links them can also help

people to understand their own and their families’ risk. The Singapore Ministry of Health routinely reports

the clusters they have identied. In their March 27

dinner functions, gyms, churches and preschools. As contact tracing in Hawaii identies local clusters, DOH

ofcials should report the types of locations, e.g., supermarkets or parties, that give rise to them so that

people get a clearer picture of the risk in Hawaii. For legal reasons, they may not be able to name specic

locations, but they can inform the public of the general categories of places where clusters are arising to

allow people to take steps to protect themselves and their ‘ohana.

Another immediate measure that can be taken to reduce transmission is to encourage everyone to use

masks when in public settings. Just a few weeks ago CDC and WHO had both recommended against the

general public using masks, but recent ndings on the COVID-19 virus have called this advice into question.

CDC is currently reconsidering its guidance. Extensive testing for coronavirus in the population of Iceland

has found that only about 50% of those who test positive are symptomatic at the time of testing. Meanwhile,

asymptomatic or pre-symptomatic people. In fact, modeling studies of outbreak clusters done for Singapore

and Tianjin, China have estimated that almost half of the transmission occurred from pre-symptomatic

persons.

to reduce transmission to others; they reduce the transfer of droplets containing virus to the environment.

Similarly, there should be no debate about the use of facemasks to prevent those with asymptomatic or

pre-symptomatic coronavirus transmitting to others. In addition, new studies have shown there is also

a protective effect of facemasks worn by those who are not infected. While they do not confer complete

protection, which has been the objection to recommending their widespread use, they can signicantly

reduce an individual’s chance of contracting or spreading an infection, especially when combined with social

distancing and frequent hand washing. Reviews of numerous studies have shown facemasks to be protective

for health care workers against both inuenza and SARS, another coronavirus. While those in the public

might be less likely to use them as correctly as health workers, they should still confer some protection

by reducing exposure to environmental contamination with coronavirus, thereby reducing their risk of

obtain adequate supplies of N95 masks and surgical masks. They must clearly be prioritized to receive the

masks they need as their risk is the greatest. Numerous scientists argue that even basic DIY masks put

together from cut-up T-shirts can be effective in reducing transmission and templates exist online for

making them. As such, strongly recommending or requiring the public to wear DIY masks until a greater

supply of conventional facemasks can be provided could prove benecial today while surgical masks are in

short supply. Guidelines from the CDC outlining what makes for an effective DIY mask would be useful for

home sewers and on-line buyers. However, public messaging on use of masks, whether DIY or surgical, must

be done carefully – it must emphasize that use of the mask is in addition to self-isolation, social distancing

and frequent handwashing, not a substitute for them. The combined effect of these combined measures

should push community transmission close to zero.

the United States as a whole, the best preliminary evidence comes from an app developed by the U.S.

technology rm, Kinsa. Kinsa produces “hi-tech” thermometers that send an individual’s temperature

information to an app which compiles temperature readings by counties across the United States.

(Unfortunately, Hawaii is not included in the Kinsa fever maps.) Kinsa’s fever map shows that “fever

clusters” have been declining across the United States during the last two weeks in March, with the largest

reductions concentrated in areas that adopted social distancing measures from mid-March (https://www.

kinsahealth.co). The bigger fever outbreaks are found in Florida, one of the last big population states to

available to speed diagnoses and improve care. This will also allow contact tracing activities to be initiated

Because the coronavirus manifests symptoms in most infected individuals within 14 days, testing of

those with clinical symptoms can detect many of the infections in the community. Many of those with

milder infections are likely to show up in outpatient settings or at doctors’ ofces. At present, however, only

a limited random subset of specimens in the inuenza surveillance system are being tested for coronavirus

surveillance. If we are to implement strong enough contact tracing to detect most active coronavirus cases

in Hawaii and temporarily remove them from the population so they cannot infect others, this testing should

be expanded to cover the entire symptomatic population that meets an appropriate clinical denition. Of

course, this must be coupled with active contact tracing for all cases. As pointed out earlier, coronavirus

The data system around testing should be enhanced to ensure essential information to guide the

response is gathered for every test conducted, whether in the State labs or private labs. This should include

exposures. The goal of this data collection is to provide actionable intelligence about the epidemic. These

data can be analyzed regularly to identify whether certain ages or occupational categories are experiencing

elevated coronavirus cases, which can trigger stronger public health messaging toward those groups.

Coupled with more complete descriptions of clusters as described earlier, this information could keep the

distancing orders and will also provide a direct measure of how effective they are. It will also determine the

susceptibility of the population to a resurgent epidemic if coronavirus is reintroduced at some future date.

If new symptomatic cases under an expanded testing regime are under control or the population prevalence

of past exposures is low, this population testing can be done less frequently. If antibody testing is made

available on a wider basis, it could also help to alleviate people’s concerns about their own status or help

them determine if it is safe to return to work.

14 days. If they are showing symptoms, they are asked to get tested to determine their own coronavirus

status. Self-isolation ensures that potentially exposed people do not themselves expose other people in

their households or workplaces while testing can help to conrm positive cases in people already showing

How productive can a good contact tracing system be in nding other people infected with COVID-19?

Much depends on how rapidly DOH staff can contact people potentially exposed to a particular case, as

rapid contact and subsequent isolation of the exposed person reduces the chance that the exposed person

will spread the virus to other people. Singapore, which has a very aggressive contact tracing system, tracked

down 53 of its rst 100 cases via contract tracing. Contact tracing is most productive when the number of

cases is a small percent of the population. As the number of cases rises, it becomes much more difcult

family members. Isolation and quarantine away from home should not be mandatory or compelled by force.”

In Hawaii, where many families live in small apartments or condominiums, isolation or quarantine within the

home is difcult and poses a risk to other family members.

coronavirus or as treatment facilities for people infected with the virus.

be given to privacy needs and legal requirements; but even privacy-conscious Europe is now considering

adopting some of them (New York Times, 3/30/2020).

IV. GRADUALLY RELAXING STATE-IMPOSED RESTRICTIONS: BASIC PRINCIPLES

The fourth step in controlling the coronavirus epidemic is for the state to gradually relax stay-at-

home and social distancing recommendations and orders and allow some economic activities that involve

groups clustered in a location, e.g., a workplace, to resume. However, this must be done with extreme

caution. Both modeling work on COVID-19 and the experience with the 1918 u have demonstrated that

once social distancing measures are discontinued, there is a serious risk of virus resurgence, that is, the

epidemic rapidly begins again. A successful shelter-in-place order plus practicing social distancing when

leaving home to obtain food or supplies is extremely effective at protecting people from contracting the

distributed vaccine will make restrictions unnecessary, but as Dr. Anthony Fauci has pointed out that is 12-18

months out in an optimistic scenario.

Until an effective treatment or vaccine is developed or antigen and antibody testing become cheap,

accurate, fast and widely available, some economic activities will not resume. This section focuses on

activities that could restart once they have been reorganized in ways that increase the safety of providers

and customers.

When will the Hawaii epidemic have declined sufciently to relax some government restrictions? The

i.e., one incubation period;

and other serious medical conditions) without resorting to crisis standards of care and use of overow

facilities, such as arenas and convention centers, to provide hospital care to patients;

not at high risk for serious COVID-19 outcomes, while maintaining or strongly recommending the more

vulnerable (older individuals or those with pre-existing conditions that expose them to higher COVID risk)

remain at home or only return to work if workplace social distancing can be guaranteed. As the stay-at-

home order is lifted, additional regulations to maintain social distancing in public and workplace settings

to the extent possible should be put into place. Singapore, for example, is marking every other seat in

restaurants and cafes as off limits to increase social distancing in these settings. Hong Kong is requiring

restaurants to operate at no more than half capacity with no more than 4 people per table and a guaranteed

1.5m spacing between tables. Depending on the workplace setting, different regulations might be adopted

to sustain social distancing protocols to the extent possible. Everyone should still be asked to wash hands

frequently and to maintain their distance from others, even in the workplace. All businesses and workplaces

“should continue to engage in physical distancing as much as possible until a vaccine is available, an

effective treatment is available, or there is no longer community transmission.” These cautionary notes apply

strongly to Hawaii where more than 18 percent of the 2018 population was 65 years or older.

In addition, as these orders are modied, the Governor might want to consider tightening the state’s

recommendation to wear masks in public and extend it for several more months. If our recommendations

provided above are implemented, all Hawaii residents will have been wearing DIY basic masks in public

since early April 2020. However, once supply constraints on surgical masks have been relieved AND the

state’s stay-at-home order is removed, then it will become even more important for everyone to use more