How Hawaii Became a Rare Covid Success Story - Bio-Defense Network
Jun 2020

How Hawaii Became a Rare Covid Success Story

The islands’ geography and small population helped. But so did two enterprising doctors who pushed for aggressive tracing and testing—and sometimes found themselves at odds.

Melanie Warner writes in Politico that in mid-February, Hawaii did not yet have any recorded cases of Covid-19, and only 15 infections had been confirmed throughout the United States. But Josh Green, the lieutenant governor and a practicing emergency room doctor, was worried. He recently had learned that a man from Japan had spent nine days in the state and then tested positive for the virus upon returning home to Nagoya. The man, apparently, was sick—and contagious—toward the end of his vacation. He and his wife, who would later test positive herself, stayed in two hotels, one on Maui and one in Waikiki. They got in rental cars, went shopping in Chinatown, ate out at more than half a dozen restaurants, and met a friend in Honolulu for coffee.

How many people had the couple unwittingly infected in that time, Green wondered? “For me, it really underscored the need to get ready. Because this thing is so contagious, it could get out of control very fast,” he says.

His fears weren’t unfounded. With 28,000 travelers pouring into Hawaii every day during the months of January and February, 20 percent of them from Asia, the state seemed fertile ground for a major Covid-19 outbreak. That was especially true on Oahu, where at least one-third of the state’s visitors cram into the hotels, stores, restaurants and beaches that line Waikiki’s 2 miles. Even without tourists, Oahu, where the bulk of the state’s population lives, is jam-packed—significantly more so than New Jersey, the nation’s most densely populated state.

But a catastrophe never came. Instead of a massive, uncontrolled outbreak, Hawaii has recorded the fewest Covid-19 cases per capita in the country. As of this writing, just one person per 100,000 has died (17 in total), and 54 per 100,000 have tested positive (762 in total). By comparison, New Hampshire and Rhode Island, two states with similar population counts, have caseloads of 406 and 1,546 per 100,000, respectively. For six weeks in April and May, new cases in Hawaii didn’t top five a day.At the beaches, where mask-free residents gather largely without tourists, you can almost start to forget about a virus that has upended lives across the globe.

Josh Green, Hawaii’s lieutenant governor and a practicing ER doctor (bottom left), grew worried in mid-February, when he learned that a man from Japan had spent nine days in Hawaii and then tested positive for coronavirus. With 25,000 travelers pouring into the state every day during January and February, 30 percent of them from Asia, Hawaii seemed a fertile ground for a major outbreak.

Few people look to the United States for coronavirus success stories, instead singling out South Korea, New Zealand, Iceland or Germany. But as America tries to navigate its way out of the first wave and considers the possibility of a second in the fall, Hawaii’s experience offers hope that, with the right efforts taken at the right time, the virus is containable. It also reveals the enduring challenge of trying to shake Covid-19: Since businesses and parks reopened in late May, the state has seen a recent, noticeable spike in cases, similar to other parts of the country. In early June, Hawaii’s streak of single-digit daily cases ended with three days of new infections in the teens.

Hawaii, at least, has past experience to fall back on now. In those critical early weeks, when cases were manageable, the state set into motion all the steps that experts across the globe have identified as crucial. It also benefited from being able to enforce a mandatory 14-day self-quarantine for arrivals in ways other states couldn’t. But the ocean alone didn’t save Hawaii. In the weeks before the arrival quarantine went into effect in late March, many expected the virus to have spread far more widely through the population than it did.

That it didn’t, and that Hawaii has continued to keep cases low, is a function not of the usual dynamics—the top-down operation helmed by a high-profile leader, as in states like New York and Michigan or countries like New Zealand and China. Hawaii’s success came at the hands of several medical doctors: Green, the outspoken lieutenant governor, along with an enterprising private physician, both of whom pushed for aggressive testing while clashing with the state’s top epidemiologist, who ran a tireless contact tracing program that has managed to track all of the state’s confirmed cases to date. In the background was a low-key governor who listened to the voices around him and made quick decisions when he needed to.

With arguments still flaring up across the country about the most effective way to manage the coronavirus response—often divided between those who want a heavy government hand and those who don’t—Hawaii’s experience shows that sometimes what works best is a multipronged, even redundant approach.

“We didn’t really have a fully proactive or decisive plan at the outset,” says Mark Mugiishi, CEO of HMSA, the state’s largest health insurer. “But with the Pacific Ocean guarding our borders and an early lockdown, we built the plane while flying it and got extraordinary results.”

“Old hat” is how Sarah Park, Hawaii’s top epidemiologist, describes contact tracing. Basic, low-tech, gumshoe work. “We’ve been doing it forever, any time there’s a disease outbreak. It’s interesting to me that everyone wants to talk about it now,” she said recently from her 4th-floor office at the state department of health in Honolulu. As a medical doctor and former disease detective with the Centers for Disease Control and Prevention‘s elite Epidemic Intelligence Service, Park hunted down West Nile infections in the United States in 2002 and SARS cases in Taiwan in 2003.

Sarah Park | Marco Garcia for Politico Magazine

In early February, Hawaii’s state epidemiologist, Sarah Park (above), and her team of six began contacting anyone arriving in the state who had recently been to China. The team, which later grew to nearly 100 people, including volunteers, has managed to hunt down contacts for all of Hawaii’s confirmed Covid-19 cases to date.

Like many states, Hawaii’s department of health had on hand a skeletal staff of investigators to respond to any outbreaks of infectious diseases. In early February, well before the state had a confirmed case, Park’s team of six began their detective work, just as they had for the emergence of hepatitis A and rat lungworm a few years earlier. Using flight information given to them by the CDC, they contacted anyone arriving in Hawaii who had recently spent time in China and informed them that, for the next 14 days, they couldn’t leave their houses or wherever they were staying. Then, every day, Park’s team called to see if the travelers were complying, and whether they were feeling sick. A few were, but not enough to warrant testing, which in February could be done only at the CDC’s lab in Atlanta with a week’s turnaround time. Park’s team also dialed around to all the people the infected Japanese man had interacted with while on Maui and Oahu. The investigators ultimately determined that, with the exception of the coffee date in Honolulu, all of his encounters were too brief to have transmitted the virus. The friend isolated himself for two weeks and never developed symptoms.

“We realized that, unlike residents, travelers stick mostly to themselves,” Park says. “They’re not going to our potlucks or our beach barbecues or hanging out in someone’s garage, where they’re in close contact with other people for a sustained period of time.”

As if to prove the point, on March 6,Hawaii got its first case—a resident returning to Honolulu on the Grand Princess cruise ship. Park’s team scrambled to figure out who in the state the individual had spent more than 10 minutes in close contact with. Most of his family members were told to isolate. Park’s team did the same with the other cases that rolled in over the next few days—an elderly man returning from Washington state with symptoms, a couple from Indiana who had become sick while vacationing on Kauai, a skier back from the slopes of Colorado, an Air Canada flight attendant staying on Maui.

“In the beginning, people weren’t really eager to talk to us,” recalls Lauren Usagawa, one of the department’s original investigators. “They didn’t know who we were, and some thought it was a scam or that they were being pranked.” But for Usagawa, who had previously worked on sexually transmitted diseases, Covid-19 interviews were relatively easy: “People are a lot more honest when you’re asking them who they had dinner with than who they’re sleeping around with.” In fact, many people, she says, were appreciative that someone was checking in on them and that officials were trying to stem the disease. Those patients or contacts who didn’t have family or friends to bring them food and other essentials for the two weeks got daily deliveries, paid for by the department of health and distributed by a network of volunteers.

Nonetheless, the infections mounted, and Park frantically began to recruit staff from around the department. She brought in investigators from the immunization and foodborne illness sections, and public health nurses from anywhere she could find them. By early April, the expanded team of 35 was still struggling to stay on top of the several hundred people who had tested positive in recent weeks and their more than 1,000 close contacts. Everyone was working nights and weekends. “I had times when partners, as well as my own staff, asked me, ‘At what point do we stop?’ Because every day it’s getting bigger and bigger, and they’re hearing from and seeing colleagues in other states stop and move on,” Park recalls. Usagawa’s first day off in four months didn’t come until the end of May. (“It felt weird,” she mused. “Like I should be doing something.” She decided to spend the day cleaning and tackling an enormous pile of laundry.)

Plenty of other states had similar government tracking programs. The difference is that Hawaii was able to keep its going as the virus spread, thanks to some combination of stamina at the department of health and the fact that the state’s high-water mark for daily cases never went above 34, on April 3. “States were doing intensive case investigation and contact tracing in the beginning. But then the wave of infections came from Europe in early March, and all hell broke loose,” says Jeff Engel, a Covid-19 senior adviser at the Council of State and Territorial Epidemiologists. “States weren’t able to keep up.”

Park’s team, which eventually grew to nearly 100 people, including volunteers, has hunted downcontacts forall of the state’s 762 confirmed cases to date, largely cutting off the virus as it sought new hosts. While Engel hasn’t done a comprehensive survey of state epidemiologists, he says he is not aware of another state that managed this. Contact tracing is most productive when cases are either stable or trending downward and represent a small percent of the population, but many states are only now hiring and training armies of investigators to ramp up their contact tracing efforts.

Although Park and her team earned praise for their contact tracing, their response in other areas, such as testing, has been heavily criticized. At one point this spring, Hawaii Congresswoman Tulsi Gabbard called for Park and her boss, Bruce Anderson, head of the state department of health, to resign.

The reason was that Park’s team, following CDC guidelines, wasn’t actually testing most of the people they reached through contact tracing, unless they developed Covid-19 symptoms; Park didn’t think it was necessary. “If you’re a close contact and you’re negative, you’re still stuck in quarantine, and we’re still monitoring you. There’s no get-out-jail-free card,” she explains. She says she was focused on preserving limited testing supplies for those most likely to spread the disease—people with significant symptoms, especially hospitalized patients, health care workers and seniors in long-term care facilities.

But this approach rankled not just Gabbard but also Green, the lieutenant governor, who faulted Park for being too entrenched in the CDC’s risk-averse culture. “All [the department of health]wanted to do was go by the CDC playbook, which normally is a good one, but not in this crisis,” says Green,who previously was a state senator and is still on call for two ER shifts a month at a Big Island hospital. He felt that extensive testing—of people with mild symptoms and even some without symptoms—was essential to control the virus, and he aggressively pushed to make sure the state’s hospitals were setting up outdoor structures where patients could easily get tested, which most major hospitals did.

Meanwhile, a fellow doctor who is an adviser to Green was coming to similar conclusions about testing. A self-described infectious disease wonk, Scott Miscovich had spent much of January and February reading any Covid-19 data he could get his hands on. He didn’t like what he was seeing. “I was very concerned about the contagious nature of the virus, and I was thinking about Hawaii’s location as the gateway to Asia,” says Miscovich, who runs eight health clinics and urgent care facilities throughout the islands. In late January, he had started placing large orders for personal protective equipment—white Tyvek suits, plastic face shields, N95 masks, hand sanitizer—for his 120-person staff, while the equipment was still available and affordable.

When his first patient with Covid-like symptoms showed up in late February, his staff at Premier Medical Group was prepared. As Miscovich tells it, the patient was HIV-positive, with a fever of 101.8, very low oxygen levels, lung sounds consistent with pneumonia and chest heaviness. And he worked for the Transportation Security Administration at the Honolulu airport. Miscovich immediately got on the phone with the department of health, which at the time was the only lab in the state able to do testing. “I’m thinking this is a slam-dunk case, but they say, ‘Hmm, nope. Did he travel from Wuhan? Was he in China? The CDC says we don’t test them.’”

“Early on, the testing restrictions were very specific, from CDC and FDA,” Park says, for her part. “Unlike private labs, public labs are held to very close scrutiny and standards, so if we start doing things not in alignment with what federal law requires, we’re jeopardizing our ability to practice.”

But from his research on Wuhan and other outbreaks in Asia, Miscovich had concluded that widespread testing was an indispensable tool, a way to know where the virus was going so you could stop it. That the department of health didn’t seem to share this view was alarming. So, with large boxes of PPE sitting in his offices, a willing staff and a decline in patient visits for non-Covid health concerns—as well as support from Green—he decided he should simply do his own testing. Not long after private labs got the go-ahead from the Food and Drug Administration, and right around the time the World Health Organization’s director-general urged health officials everywhere to “test, test, test,” Miscovich secured agreements for a supply of tests from Hawaii’s two biggest labs. He then pitched Honolulu Mayor Kirk Caldwell on the drive-through idea, a model South Korea had pioneered. A week later, on March 21, the city joined Premier Medical Group to offer free testing at a waterfront park in Honolulu. About 450 people were tested; 24 of them were positive.

After that, Miscovich and his staff, including two of his adult children, traveled to Maui and the Big Island, then back to Oahu. Working directly with the mayors, they pitched their tents anywhere that could accommodate large numbers of cars—public parks, community centers, boat harbors and the huge soccer complex where, in gentler times, my son played games every weekend. Miscovich didn’t test everyone who showed up, but his net was far wider than what the department of health was recommending.

“Part of the beauty of the drive-through was that we got to talk face-to-face with almost 45,000 people,” Miscovich says. “We answered their questions and told them when they needed to be tested. We told them, ‘Just because you might test negative doesn’t mean you don’t have to come back if you develop symptoms.’ At least four of our positives initially tested negative, but when they coughed four days later, they came back to get a test.” He also set up roughly 40 testing sites for private employers, nursing homes and homeless camps.

So far, Miscovich and his team have done 17,000 tests, about a quarter of the state’s total, including nearly a quarter of Hawaii’s positive results. In March and April, when Hawaii’s cases were building, his tests accounted for almost half the state’s total tests and 40 percent of its positives. In late March, Hawaii ranked seventh in the nation for per capita tests. (Today, with a relatively low caseload, it ranks near the bottom.)

While they didn’t see eye to eye, Miscovich’s work effectively fed into Park’s: Each new case he identified was one more that she and her team could trace, isolating people and breaking the chain of transmission. But Miscovich wasn’t about to leave it up to the department of health. He says he personally called each of his positive patients, and then his staff showed up to test their whole family and, in some cases, friends and co-workers. In early April, to handle the increase in cases, he rented office space, hired 20 additional employees and had two dozen phone lines installed, so his patients and their contacts could be called and monitored daily. Miscovich says he has funded these efforts and the public drive-throughs with his own money, a total of about $500,000, half of which he has since gotten back from insurance companies.

What’s remarkable about Hawaii’s success is how much of it was driven by Miscovich’s and Park’s determination. David Ige, the state’s two-term Democratic governor, has not gotten high marks from the public for his response to the virus—perhaps because some of his remarks at press conferences left residents confused; in one case, he reversed course on rules about when businesses could reopen. In a Civil Beat poll released in late May, only 20 percent of respondents expressed a positive view of the governor, compared with 69 percent for Green, the lieutenant governor, who emerged as one of the state’s most vocal leaders on Covid-19.

While Ige told me he credits the state’s early start on contact tracing for suppressing the caseload and mitigating the health impacts of the pandemic, he acknowledges that private testing, by Miscovich as well as at some hospitals, played an important role. He also called his decision to implement the 14-day quarantine rule for arrivals—which the state imposed on March 25, along with its stay-at-home order—“strategically and fundamentally important.” But unlike New Zealand, which carted all of its arriving travelers off to designated hotels, Hawaii didn’t have an airtight system; several dozen visitors have been arrested for frolicking on the beach or otherwise ignoring the quarantine rules.

Ige seemed most animated when he brought up another factor he deemed important: the sense of community and responsibility for which Hawaiians are known. In Hong Kong, health officials kept tabs on the infected and potentially infected with electronic medical bracelets, and Singapore made sure people stayed at home with a phone app that verified their location. In Hawaii, the state relied on the spirit of aloha. “Maybe it’s because we’re on an island, but people here understand that what we do impacts our neighbors and friends,” Ige said, in the relaxed tone he is known for. “People took the mandates to stay at home and self-isolate seriously, and they encouraged each other to implement it.”

Both Ige and Green are careful not to suggest the state has in any way beaten the virus. Both officials are prepared for the possibility that higher caseloads are going to become the new normal as people continue to move around and as tourists return. Ige is expected to announce that Hawaii will allow visitors into the state quarantine-free if they have a negative test upon boarding the plane. The program, similar to what Alaska and Iceland have implemented, would still require those without a recent test to quarantine.

For now, Park’s contract tracing continues, and in fact has gotten hectic again with the recent bumps in cases. As the department of health’s testing capacity has increased, Miscovich has scaled back on public tests, focusing on specific populations, such as nursing homes, while also doing some antibody testing. But he says he is ready to ramp up again if needed.

When higher caseloads inevitably appear, Green says he thinks the state will be ready to respond without the extreme shutdowns that were necessary in March. The department of health, for instance, now has on call an additional 160 volunteer contact tracers for when the need arises. “We’ve beefed up our contact tracing and testing capacity by orders of magnitude,” he says. “And a lot of our understanding about the virus has matured. We’re stronger, and we can definitely manage it.”

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