A video explaining the transmission and mitigation of COVID-19, produced by Hawaiʻi Emergency Management Agency (HIEMA), features Thomas Lee, an assistant professor of epidemiology in the University of Hawaiʻi at Mānoa Office of Public Health Studies in the Myron B. Thompson School of Social Work, and lead modeler and forecaster for HIEMA.

Lee described the three types of transmission of COVID-19 and how to best reduce the spread of the virus. The types of transmission are droplets, aerosolized and fomite, which means surface.

“We know that COVID-19 prefers metallic surfaces that are smooth, so anything that’s cloth or has texture to it, it’s less likely to survive,” said Lee. “So droplets and aerosolized are related in that when you cough or sneeze the first six feet projects out, but because it’s within some sort of liquid substance it’s going to fall down because it’s heavier.”

In cold and dry climates, like Las Vegas, those droplets will linger in the air longer in comparison to a humid climate like Hawaiʻi, because water in the air will weigh the droplets down causing them to fall to the ground.

However, transmission through droplets and aerosolization can occur with older air-conditioning units that do not bring in fresh air and are continually recycling potentially contaminated air. Lee explains that spending time outdoors while social distancing is safer than staying indoors with an air-conditioning unit that recycles air.

“COVID-19 is an envelope virus, which means that it is pretty easy to kill. Even just regular soap and water is such an effective tool,” added Lee. “We can all do our part to reduce the risk of transmission for COVID-19. It starts with wearing a mask, washing your hands and staying home when you’re sick.”

To help demonstrate the power of public health in Hawaiʻi, two University of Hawaiʻi at Mānoa Office of Public Health Studies faculty launched a social media campaign #PowerOfPublicHealth808 to promote wearing face masks to help slow the spread of COVID-19.

Denise Nelson-Hurwitz, an assistant professor at the Office of Public Health Studies in the Myron B. Thompson School of Social Work, and Lisa Kehl practicum coordinator at the Office of Public Health Studies, designed the social media campaign #PowerOfPublicHealth808 to empower Hawaiʻi’s community to do their part to help keep people safe by wearing a mask during the COVID-19 pandemic.

“We wanted the campaign, and hashtag, to be empowering, and relevant to our local community,” said Kehl. “We feel the aloha spirit practiced throughout Hawaiʻi, and our strong sense of community encourages us to protect our neighbors, families and ourselves from COVID-19 by practicing physical distancing and wearing masks.”

To participate, post a photo of you, your family or organization, wearing face masks and add the caption “I/we wear a mask to protect…” on Facebook, Instagram or Twitter, using the hashtag #PowerOfPublicHealth808.

“We’ve seen growing participation on Facebook and Twitter from many age groups,” said Nelson-Hurwitz. “I’ve especially loved seeing our students and graduates living out their public health training and posting their masked selfies.”

Among those showing support for the social media campaign are Gov. David Ige and First Lady Dawn Amano-Ige, who posted a photo wearing their masks on Facebook and Instagram.

“Wearing a mask has been effective in limiting the transmission of respiratory diseases for over a century. It is more effective at protecting others, but it is still effective at reducing the risk of getting sick yourself,” said Nelson-Hurwitz. “We in Hawaiʻi can do this for our kupuna and our keiki, for our high-risk populations, including Native Hawaiians and other Pacific Islanders, and we can again demonstrate to the world why we’re lucky to live in Hawaiʻi.“

Public, private and non-profit organizations and agencies formed the Behavioral Health and Homelessness Statewide Unified Response Group (BHHSURG) with the support of the University of Hawaiʻi at Mānoa, to break down silos and to ensure the community’s most vulnerable receive the care they need, especially during the COVID-19 pandemic.

The Hawaiʻi Department of Health has operated the TQIC with a number of community partners, including the Institute for Human Services; the Hawaiʻi Homeless Healthcare Hui; Local 5, the union that represents hospitality, healthcare and food service workers; and others. Collectively, the groups provided the necessary human resources support, including healthcare professionals, case managers and round-the-clock security for the center to open its doors in late March.

As a result, the center has been able to free up hospital space to improve care capacity, save on medical costs, and keep the community protected from potentially infected individuals.

According to a recent report prepared by the Department of Health and the UH Mānoa Office of Public Health Studies, data collected from clients at the center has also proven that such a facility has been effective in tackling a deeper, more pervasive challenge: the need for a behavioral health crisis stabilization center to take care of the health and social needs of homeless individuals, including those with substance use disorder.

“The population we serve is often marginalized but the services we provide are vitally important to the overall health and wellbeing of our entire community, and is a necessary component to safely reopening our state,” said Edward Mersereau, the Department of Health’s deputy director of behavioral health.

Mersereau said unsheltered individuals generally have other chronic, pre-existing health conditions such as undiagnosed or unmanaged diabetes and heart disease and have a disproportionately high rate of behavioral health conditions, including substance use disorders. This makes their care more complex, requiring an interdisciplinary approach.

“Through our work at UH on analytics, evaluation and the CARES Line, we are grateful for the opportunity for UH to partner with DOH on this proof of concept of a behavioral health crisis stabilization center which has the potential to save the state the large medical and economic costs of behavioral health crises,” said Victoria Fan, a UH Mānoa associate professor in the Myron B. Thompson School of Social Work.

For more see the Hawaiʻi Department of Health website.

When Hawaiʻi’s government officials and policy makers want to know what lies ahead in the COVID-19pandemic, they look to University of Hawaiʻi at Mānoa’s Thomas Lee, an assistant professor of epidemiology in the Office of Public Health Studies in the Myron B. Thompson School of Social Work, to provide some answers. In his role as the forecaster and modeler for Hawaiʻi’s response effort, Lee analyzes reams of data and gives state policy makers a picture of what the coming months may hold.

Lee creates epidemiological models of Hawaiʻi’s current COVID-19 infection rate and test results. As part the Hawaiʻi Emergency Management Agency (HI-EMA) COVID-19 Emergency Response Team, Lee synthesizes these models with the latest science on coronavirus transmission rates, population risk factors and the effects of physical distancing to create forecasts of the pandemic’s possible impacts on the state.

“The goal of my work is to provide decision makers in Hawaiʻi with the best available information on the possible future spread and impacts of COVID-19,” Lee said. When he began this work in early April, the urgent focus was to predict infections for the coming days and weeks. Now, as the state looks ahead to opening up, his tasks have shifted to figuring out the outcomes of different scenarios.

Lee is currently figuring out how Hawaiʻi’s case count may change if the state decides to screen all travelers, rather than not screen them. He is working on predicting how many COVID-19 patients may require long-term hospitalization, and at what point it makes sense for the state to create a dedicated skilled nursing facility to care for them. His scenarios on future cases inform HI-EMA’s calculations on how much personal protective equipment Hawaiʻi will need for the second wave of infections.

Lee’s background

Born and raised in Hawaiʻi, Lee is an alumnus of the public health program for which he now teaches.

“The UH Mānoa public health program does a great job in training epidemiologists to be multidisciplinary,” Lee said. Prior to the pandemic, most of his research focused on modeling rates of chronic conditions, such as Alzheimer disease and risk factors for depression.

As a U.S. Army reservist placed on active duty, Lee relies on his military training to understand the logistics and planning aspects of the state’s larger pandemic response effort. His role as HI-EMA‘s forecaster requires not only data analysis skills, but also the ability to engage in communications, education, coordination and planning.

“In the military and public health, I’ve learned to look at problems holistically, and that perspective has certainly been needed in this response effort,” he said.

As part of his work at UH Mānoa, Lee participates with other faculty members in the Hawaiʻi Pandemic Applied Modeling (HiPAM) workgroup. This group includes epidemiologists, data scientists and health care workers, and helps the state in adapting models and other tools for Hawaiʻi’s unique context.

“Thomas has a rare combination of strong scientific and technical expertise in epidemiology, as well as humility and excellent powers of listening and reflection that are the basis of his excellent communication skills,” said Victoria Fan, chair of the HiPAM workgroup and an associate professor at UH Mānoa. “I believe Thomas is instrumental for the Office of Public Health Studies in bridging the gap between the academic and the real world.”

Hawaiʻi moving forward

Lee said that an important part of his work is communicating to policy makers the limitations of the data. “I don’t have a crystal ball,” he said. “My job is to communicate the forecasts along with the assumptions and caveats that we used to develop the forecasts.” Any possible scenario could lead to a range of outcomes, and Lee feels a massive responsibility to explain to policy makers that his models are meant to provide likely outcomes, not definitive answers.

Ultimately, Hawaiʻi’s ability to move forward will depend on each person’s efforts to adhere to the best public health practices, such as maintaining physical distancing and staying informed.

“We all have an impact on how we continue to open up, and how healthy we are as a state,” Lee said. “Everyone has a responsibility to do their best.”

Master of Public Health students, Angel Lynn Talana and Taylor Ronquillo have created a COVID-19 Resource Guide and Volunteer Opportunities Guide as part of their special practicum. This resource guide includes information about COVID-19 parenting resources, childcare services, food support, financial support, and more. They also compiled a volunteer list for those who wish to help communities in need.

These lists will be updated every other week so make sure to check regularly for any updated resources and volunteer opportunities.

Office of Public Health Studies Assistant Professor Thomas Lee on what we can learn from the COVID-19 response of South Korea and Taiwan.

Challenges arising from the COVID-19 pandemic have resulted in ever-changing information and guidance being given to behavioral health and homeless services providers, slowing down their ability to help vulnerable populations in Hawaiʻiduring the crisis.

In an urgent effort, three state agencies mobilized and launched the Behavioral Health and Homelessness Services Unified Response Group (BHHSURG) with support from the University of Hawaiʻi at Mānoa. This groundbreaking initiative makes Hawaiʻi the only state to integrate behavioral health and homelessness in one place with a website that centralizes and unifies information. It coordinates resources given to providers, helping reduce confusion, which allows providers to assist their clients safely.

BHHSURG is an innovative partnership. The State Department of Health Behavioral Health Administration, the Governor’s Coordinator on Homelessness and the State Department of Human Services Office of Homeless Programs with support from UH Mānoa Myron B. Thompson School of Social Work and other partners have pooled resources and efforts to address long-standing gaps in the system of care for vulnerable populations.

“The platform is groundbreaking in the way it has been organized,” said Victoria Fan, UH Mānoa associate professor of public health. “It hasn’t been done before. We believe it will help many who are in need of these services. UH Mānoa has played a key role in organizing and disseminating critical information and resources to providers so that vulnerable populations can continue to receive services during this unprecedented time.”

UH Mānoa experts have helped to develop the program on many levels including coordination and integration of resources through data and analytics, as well as other operational, logistical and communications support.

Undergraduate students have been helping by staying abreast of federal policies such as Centers for Disease Control and Prevention guidance for testing and telehealth. Graduate students have been translating the information they find into operational and clinical tools that providers can use to help their clients.

“I look at my medications: take with food, don’t take on an empty stomach … I never have money. I never have food … Sometimes I go to the churches, but a lot of the food is canned goods stuff … It contributes a whole lot [to] not eating healthy and poor diet.”

The man quoted above has a car, which he sleeps in, but no money for gas. He has no phone and no one to help care for him as his daughter lives far away.

He was telling his story for a University of Hawaii study several years ago about why his heart disease got so bad that he was hospitalized. Even in the best of times, it can be hard to eat healthy, exercise, take medications on schedule, and follow doctor’s recommendations to prevent and manage chronic diseases like diabetes or heart disease.

For people with limited funds, unstable housing, and no social support, as another woman with diabetes and heart disease said in the UH study: “It’s a day-to-day struggle. It’s stressful because the cost of keeping healthy is expensive and I have no money.”

These challenges lead to deep inequalities in our communities and in our health care systems around the burden and consequences of chronic disease. In the necessary but massive disruption of daily life around the COVID-19 pandemic, there are now even more competing priorities in staying safe while maintaining physical distancing — stresses from urgent alerts, store closures, confusions around changing guidance, medication shortages, loss of health insurance coverage due to job loss, extreme caution around health system use.

Even those rich with resources are struggling as stores run out of rice, pasta, beans and spinach, along with toilet paper. Those who relied on community resources and food banks may be in deeper need. Many who were living paycheck to paycheck have lost their jobs and are newly reaching out for basic necessities.

We will continue to hear a loud, important, and steady drumbeat of messages around the risk and consequences from COVID-19, a highly contagious disease, in order to keep our communities safe. The quiet symphony of synergistic recommendations for chronic disease prevention and management must not be lost.

To Prevent Future Morbidity

This is necessary to prevent future morbidity and mortality for chronic conditions, the most prevalent conditions in the world, and also because 1) those with chronic disease, especially uncontrolled chronic disease, appear to be more susceptible to hospitalization and death from COVID-19; and 2) uncontrolled chronic disease can lead to urgent health crises that will strain fragile health systems now as well as long into the future.

Preliminary evidence from the United States highlights that most COVID-19 deaths have had an underlying condition, with diabetes, chronic lung disease, and cardiovascular disease figuring prominently. Smoking/vaping are also risk factors, putting young people at surprising risk, especially in a state like Hawaii where over a third of youth report vaping.

Public health draws upon a framework called the social ecological model to understand the levels of influence that help to keep a person healthy. The model starts with an individual in the center and around this puts layers of influence starting with interpersonal factors (families, relationships) then organizational factors (health care, schools) then community (neighborhoods, culture, social networks) and finally policy (laws).

Each of these layers have been disrupted by the COVID-19 pandemic.

Individuals are experiencing stress and worry, even depression, around health, job loss, and futures for themselves and their families. With 37% of Hawaii’s labor force filing unemployment claims and many others facing cuts to already low wages, more of our community will be pushed into homelessness and poverty.

Families may be too far apart, or too close together for too many days in a row, to provide full support. Neighborhoods are disrupted and cultural fabrics have been challenged. Schools, pharmacies, and primary care providers may be closed. Laws are changing and uncertainty exists around what is yet to come.

Deep Health Inequalities

Innovative solutions to help prevent and manage chronic disease are available across the levels of the social ecological model even in this time of crisis. Numerous health and social agencies, businesses, and individuals have stepped up across our state in support of our communities.

Options include individual-level considerations (e.g., how to exercise during social distancing; tobacco quit lines available virtually); interpersonal-level efforts (e.g., intimate partner and family supports); organizational-level responses (e.g., online diabetes prevention programs; school lunch pick-ups), community-level responses (e.g., mutual aid efforts; funds to share with communities in need, cultural practice adaptations), and policy-level changes (e.g., households scheduled to renew food stamp benefits may receive a six-month extension).

Effort and solutions must be distributed across our communities so that certain groups who already have deep health inequities are not put even deeper at risk. The UH study found many hospitalized with heart failure or uncontrolled diabetes had extreme social vulnerability (e.g., homeless, poverty, no social support).

Other challenges to managing chronic conditions included difficulty interacting with the health system or providers, or limited access to care because of transportation or insurance barriers, limited health-related knowledge, and behavioral health issues (e.g., substance abuse, mental illness). All of these issues still exist, and may be exacerbated, in the time of COVID-19.

These issues will likely have deep impacts in vulnerable communities, including non-English speakers who already struggle to find understandable guidance with culturally-relevant information, or those who live in rural communities with insufficient primary care providers. Though we currently lack the data specificity to investigate these concerns, Native Hawaiians and Pacific Islanders may be at higher risk due to greater socioeconomic vulnerability and high rates of chronic conditions.

COVID-19 has acutely highlighted all of the weaknesses in our economic, societal, and health systems. In order to be more resilient in the future, we have to address those weaknesses, starting with assuring a living wage, adequate social safety nets, resources for the most vulnerable in our communities, equity in education, and integrated health systems.

The noise of an outbreak can easily drown out other but equally important health messages. But infectious diseases are not delinked from chronic diseases. Let go of one, and other will worsen. Turn our backs on prevention and management of chronic diseases and more of our community will be at risk of having negative outcomes from a COVID-19 infection.

The tools for fighting this pandemic are not limited to just social distancing — they also include the arsenal of innovative approaches for preventing and managing chronic conditions.

These can build a new symphony, which like Andrea Bocelli’s Easter Sunday Concert may be unexpectedly virtual but still powerful, able to uplift and support wellness and chronic disease management.

Public health recognizes that everyone from the community member to the policy maker is required to create resilient communities. Walkable neighborhoods, grocery stores with healthy affordable foods, tobacco-free norms, living wage, are necessities. The inclusive music must continue to be written so everyone can enjoy the melody of health.

Editor’s note: Dr. Catherine Pirkle (academic) and Dr. Lance Ching (epidemiologist) of HHIET are co-authors.

About the Authors

Tetine Sentell is a professor and the director-chair of the Office of Public Health Studies at the University of Hawaii Manoa. She is the principle investigator of the Healthy Hawaii Initiative Evaluation Team and her research focuses on untangling the complex relationship between health disparities, education, literacy, English language proficiency, and other social factors.

Lola Irvin is the administrator of the Chronic Disease Prevention and Health Promotion Division at the Hawaii Department of Health, which has categorical program areas in tobacco, nutrition, physical activity, obesity prevention, asthma, cancer, diabetes, heart disease and stroke. The CDPHPD employs systems, policies, and environmental change strategies to support the prevention and management of chronic disease.

Despite the discouraging stream of announcements of new coronavirus cases that have been detected in Hawaii, data compiled by Johns Hopkins University shows that as of Monday this state had the third- lowest per capita infection rate of any state.

While that is good news for Hawaii residents and the state’s health care system, experts warn it is too soon to begin relaxing the statewide stay-at-home order, quarantine orders or other restrictions that have been imposed to try to prevent the spread of the new coronavirus.

Dr. Mark Mugiishi, president and CEO of the Hawaii Medical Service Association, on Monday told the House Select Committee on COVID-19 Economic and Financial Preparedness that despite some positive signs, COVID-19 remains “highly infectious and devastating, and right now there is no vaccine, no cure, no evidence of herd immunity.”

“So, as we gain control of this first outbreak, which is really wonderfully, happily, slowly we’re starting to see the light at the end of the tunnel, but we must be careful not to trigger a second or a third outbreak in our attempts to recover,” Mugiishi said.

Adjutant Gen. Kenneth Hara, incident commander with the Hawaii Emergency Management Agency, said during the same online discussion Monday that “we really did flatten the curve,” and announced there were only five new positive test results Monday for coronavirus cases. It has become routine during the past three weeks for state health officials to report 20 or more new cases per day.

The data provided by Johns Hopkins and published by time.com shows that only Minnesota and West Virginia have per capita infection rates that are lower than Hawaii’s rate of 36 coronavirus cases per 100,000 population. That is far below the national rate of 177 infections per 100,000 population.

It is also noteworthy that Hawaii tests for coronavirus at a considerably higher rate than most states. According to data compiled by Vox, Hawaii continues to rank among the top 10 states for testing per capita, which suggests Hawaii’s infection rate may be more accurate than rates reported by some other states.

Gov. David Ige cited the state’s early push to become certified to conduct coronavirus testing as a factor that has helped cope with the pandemic, adding that “we’ve also been very aggressive in setting up testing sites across the state.”

“Also, our quality health care system has kept hospitalization, intensive care and mortality rates among the lowest in the country,” Ige said in a written statement. “And the collective actions of responsible Hawaii residents who are obeying stay-at-home orders have contributed to Hawaii’s ranking as one of the best-performing states in the country in dealing with this pandemic.”

University of Hawaii- Manoa epidemiology professor Alan Katz also has cited Hawaii’s geography as a considerable advantage, since this state has the means to almost entirely shut off the flow of people into the islands. Other states cannot exercise that degree of control over people’s travel, and therefore have less control over the disease’s spread.

“We took strong action, and I believe the population has been adhering to the recommendations” for social distancing as well as the stay-at-home orders, Katz said. “I’m not seeing the sort of aggregate crowds you are seeing on the news in other places.”

He noted news reports of people gathering to party on the Kaneohe Bay sandbar, or a couple who arrived on Kauai and ignored quarantine warnings and were finally arrested, “but I think that’s more the exception than the rule. I think people have been behaving appropriately.”

Katz said he would expect to see a downward trend in the number of infections about two weeks after the statewide stay-at-home order went into effect March 25, which appears to be happening “and which I hope will continue.”

But he said the state needs to make sure that is a true trend and not meaningless variation in the data. “I think we do have to wait until the end of the month — minimum, the end of the month,” he said.

Tim Brown, a senior fellow at the East-West Center with expertise in infectious disease and behavioral epidemiology, said the stay-home order and social distancing, for the most part, are “having the desired effect.”

There has been relatively slow growth in hospitalizations and deaths, and “because this virus usually manifests in symptoms in less than two weeks, if the virus were widespread in the community, these numbers would be growing more rapidly,” Brown told the House select committee Monday.

But before the state can lift the statewide lockdown, it must have the capacity to more rapidly test suspected cases, quickly trace their contacts and quarantine people as needed, he said. The state also needs “data to inform triggers for reimposing lockdown should the epidemic surge,” Brown said.

Hawaii health officials will need that extra lab capacity and other resources to cope with the new coronavirus for the next one to two years until a vaccine is developed, he said.

“If we were to lift the shutdown measures now and go back to our previous way of life, we could easily find ourselves in a New York type of situation within a month or two,” he said. He cited the example of Singapore, which has traced clusters of infections around workplaces, preschools, gyms, shipyards, private functions and dormitories, he said.

China is now seeing new coronavirus cases that are being imported into the country by travelers, Katz said, which also underscores the need for careful planning as businesses seek to reopen and the tourism industry attempts to restart.

“Because things are looking pretty good here, I’m hoping that we will be able to adopt the best strategic plans for getting back to normal, but it’s really sort of tiptoeing back into it,” Katz said. “You can’t just sort of say, ‘It’s over.’ It’s a slow process of what is the next step, step by step, and watching to make sure that things don’t rebound.”