COVID-19

Hawaii was poised to hit its peak coronavirus medical need as soon as this past weekend, according to one widely cited coronavirus research institute. Yet the local numbers continue to climb and are likely to exceed 500 this week, begging the question: why doesn't the state have a solid idea of when the surge will come and whether it is prepared?

U.S. universities using statistical modeling to project the course of the coronavirus through individual states have sought to answer just when cases would peak and whether there are enough health care resources to avoid overwhelming hospitals as seen in New York and Italy.

Across the country, states have scrambled to pull information from the statistical models to help them determine when to impose measures like stay-at-home orders. But the models can be notoriously inaccurate.

Some local researchers think the projections may not apply well to Hawaii and urge developing better information to help local health care and government officials make their life-and-death decisions.

One of the main models used by the White House comes out of the University of Washington's Institute for Health Metrics and Evaluation. IHME projects if there are sufficient health care system needs like hospital beds, and how many deaths states might expect.

In March, the institute said Hawaii's draw on medical resources would peak in early May. According to those early estimates, Hawaii would fall short by 154 hospital beds and 123 intensive care unit beds. Most concerning, it predicted Hawaii would see 374 COVID-19 deaths by early August. 

Then earlier this month, the institute's researchers sharply changed those projections. They said Hawaii’s peak would instead occur as early as this past weekend. And, it concluded, the state would see little to no hospital bed shortages and only about 100 deaths by August.

Nick Redding, the executive director of the Hawaii Data Collaborative, a local data analysis project, says the University of Washington model is the best he’s seen. But he isn’t comfortable with the latest changes.

"Basically, because our hospitalization rate and death rate is so low, they had to make some assumptions in their model," he said. When the researchers applied their recent update across all 50 states, Redding believes it made the model less valid for Hawaii, although perhaps more so for New York and other states.

The University of Washington's original, dire projections for Hawaii may be more reliable than the latest optimistic numbers, Redding said.

Regardless, he thinks there’s room for improvement and the Hawaii Data Collaborative is working on a local statistical model of its own.

"We've got to do better. We've got to get a localized model informed by local experts, and daily updated data from the hospitals that we can start to track the model," Redding said. 

"We want to put a call out for, 'Hey, let's as a community come together and get better models.'"

Redding said more information about day-to-day hospital capacity would give the state a better understanding of whether it can ride out the pandemic. 

Lt. Gov. Josh Green, an emergency room physician who has been critical about aspects of the state administration's response to the pandemic, recently began posting on Instagram information on hospital bed counts and available ventilators, among other data.

Hawaii’s available hospital bed capacity is currently at about 45 percent capacity and ICU beds at 28 percent. Before the COVID-19 outbreak cancelled elective surgeries, hospital occupancy was at about 65 percent. 

Perhaps most importantly, experts say, what is needed is more information about who is infected.

Dr. Thomas Lee, an epidemiologist and a professor at the University of Hawaii’s public health program, said Hawaii has challenges.

"We're different from some other states. Unfortunately, we do have a homeless situation. But knowing that that is a potential hot spot, the other hot spots are marginalized communities where English is a second language and they may not be getting the information, the health education that everyone else is getting," he said. 

If researchers could see the status of COVID-19 in terms of its potential spread in marginalized, underserved communities, he said it would improve some of the modeling.

Redding said even counting the number of people at hospitals suspected of having the virus, but who haven’t yet tested positive, could go a long way.

According to Lee, the state should be looking at places like South Korea or Taiwan that use extensive contact tracing to notify people who are around those with the illness.

"They send out messages to people who live within those vicinities and say, 'Hey, be aware of the fact that you do have people who have tested positive in your community," Lee said. "If done in the right manner, it's not going to incite fear or aggressive behavior."

The state Department of Health posts maps that generally show where the positive COVID-19 cases are across Hawaii. 

But because many of the cases are travel-related, the maps don’t reflect if the virus is circulating in communities with high numbers of cases.

The department says that separately mapping the community-spread cases that number about 92 are not important when it comes to determining the risk of acquiring the coronavirus. 

And right now, it says, it’s fine with the 30 or so people tracing and notifying contacts of those who test positive.

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COVID-19

The novel coronavirus has upended life in Hawaii and been an economic disaster, but Hawaii residents do have some unique advantages as public health officials fight to slow the local spread of the disease.

Even while residents watch and worry as the daily count of infections in Hawaii climbs — it stands at 224 today — University of Hawai‘i at Mānoa epidemiology professor Alan Katz points out that this state has an enormous advantage as an isolated island chain.

The history of the 1918 Spanish Flu pandemic shows that a few isolated areas that imposed tight restrictions on who could come in and who could leave survived with few impacts from that disease, he said.

“We are an island, so we have much, much better control of borders than any land-locked state does because it’s virtually impossible for some place in the middle of the United States to survey all of their boundaries,” Katz said.

The movement of visitors into Hawaii from the rest of the nation has been choked off in a way that is virtually impossible in other states, and Hawaii officials are poised to further restrict traffic between the population centers within Hawaii with an interisland quarantine.

The Hawaii Tourism Authority announced Tuesday the visitor count arriving in Hawaii on Monday plummeted to 121, down from an average of about 30,000 per day a year ago at this time. In all, 681 people arrived Monday on 41 flights, and the vast majority of those were returning residents or flight crew members.

Even within the state, much of Hawaii including the neighbor islands is sparsely populated and rural, which reduces the chances of a major outbreak, Katz said.

“Rural means less densely populated and the key risk for person-to-person transmission is close person-to-person contact,” said Katz. “That’s why social distancing is really the key for mitigation of transmission.”

Even with the travel quarantine in place along with the closures of bars and non-essential businesses and the statewide restrictions on residents’ movements, Katz said Hawaii will inevitably see more cases because the incubation period for COVID-19 is up to 14 days.

But Hawaii has also been increasingly aggressive about testing people for coronavirus. State health officials said Monday they have so far tested 8,936 people for the novel coronavirus, which is far more tests per capita than many other states.

According to coronavirus testing data maintained by the website Vox, Hawaii ranks sixth in the nation for the number of people per capita who have been tested for the disease. That puts Hawaii’s testing effort on par with Massachusetts, which has nearly 5,000 coronavirus cases.

The state’s approach of testing only people who show symptoms is “more focused and more valuable than simply going out and testing everyone who wants to be tested,” according to state Department of Health Director Bruce Anderson.

“We’re actually not far behind (South Korea) in terms of tests per capita,” Anderson told the Senate Special Committee on COVID-19 on Friday.

Hawaii’s 14-day quarantine program to try to block infected people from coming into the state “seems like it’s working,” Anderson said, but added that quarantine will not help to cope with cases that are already in Hawaii.

“I think we’re doing it better than most are,” he said of managing the cases that are already here. “Our numbers are down. We’re able to thoroughly investigate the cases that we know about and identify contacts and of course they’re being quarantined if they’re close contacts. If the numbers get much bigger, we’re going to have a much more difficult time managing that.”

Still, he added that “we all anticipate a time when we’re going to start seeing much more community spread. It’s practically impossible to avoid, and our challenge is to keep the numbers down to a level where we can manage the cases that are occurring and of course tamp down the number of cases as best we can through our contact investigations.”

The number of confirmed coronavirus cases in Hawaii has nearly doubled from 120 to 224 since Anderson made those comments, and Katz urged residents to take health guidelines seriously to avoid a major outbreak..

“The most important thing you can do is maintain social distancing. Stay 6 feet away from each other. That’s going to really dramatically mitigate person-to-person spread of this. If you’re not essential, if you’re supposed to be at home try to stay at home. Don’t aggregate in groups,” Katz said.

And while some people may be ignoring city and state stay-at-home orders, the orders are being enforced in Honolulu. Police Chief Susan Ballad said today her officers have issued about 1,500 warnings since March 23, handed out about 180 citations, and made nine arrests for violating the emergency orders.

Katz said his sense is that “folks in the state of Hawaii are behaving in an incredibly responsible manner.”

“People are basically adhering to the recommendations, the guidelines and the mandates,” he said. “I think that’s unbelievably important…Social distancing at this point — at this critical point in the pandemic — is the way we’re going to mitigate the person-to-person spread.”

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COVID-19

Counseling services

Community 24/7 services

  • Crisis Text Line – text ALOHA to 741‐741
  • National Suicide Prevention Lifeline – 1‐800‐273‐TALK (8255)
  • Crisis Line of Hawai‛i – 832‐3100 on O‛ahu; 1‐800‐753‐6879 on neighbor islands

Other resources in response to the COVID-19 pandemic:

Apps

  • Headspace – mindfulness and meditation app
  • Virtual Hope Box – individuals can personalize the app to help with coping and stress management
  • PFA (psychological first aid) mobile – app for providers responding to adults and children during an organized response effort

“It feels a little like practicing medicine in a war and I am not ready for this …”

This was a statement from a very close friend, who is a family doctor in Canada. She was describing her anxiety around a treatment decision that required balancing concerns about bringing an older patient into her clinic for diagnosis and treatment of a chronic condition versus delaying standard care in order to reduce that patient’s risk of acquiring a COVID-19 infection.

Many of our doctors here are currently making similarly challenging treatment and management decisions. Almost no one is trained for this, emotionally or clinically.

As recently highlighted in an editorial in the Lancet, which is the world’s premier medical journal, health care workers are currently our most precious resource. They are at the frontlines of the pandemic and one of the groups most at risk of infection.

The risks taken by our health care workers are well-recognized, as is the unconscionable situation in which so many providers lack personal protective equipment, despite weeks of forewarning that a global pandemic was nearly inevitable.

Equally concerning is that health care workers can be a source of infection themselves, especially when they lack the equipment and support that would protect patients and other providers, and in a context in which it is still unclear how much transmission of COVID-19 occurs by asymptomatic individuals. There is no doubt that insufficient and maldistributed PPEs across the United States, and here in Hawaii, is an acute crisis that cannot be ignored.

However, our providers need other forms of support too, including childcare and eldercare. With schools closed, like everyone else, our health care providers are balancing personal and professional roles and responsibilities.

Our heath care workforce is much larger than just doctors and nurses. It includes staff from a wide variety of disciplines (e.g., pharmacists, information technology specialists, laboratory technicians, interpreters, social workers, etc.) all of whom are critical to the proper functioning of our health system.

One group that is particularly vital, but frequently overlooked and under-celebrated, is custodial staff. In a context in which environmental cleaning and disinfection is paramount, both in and out of health care settings, assuring the health and wellbeing of our custodial staff should be among our highest priorities.

However, all health care staff at the moment need support, as the best way through this crisis is the full and coordinated mobilization of those who are trained to care for sick patients and their families.

While health care workers are our most valuable resource, our health system is currently our most valuable infrastructure. A health system is more than just hospitals. While definitions of health systems vary considerably by professional organization, generally speaking they encompass those that govern and guide health care decisions (policymakers and departments of health), entities that finance services (insurers, Medicaid and Medicare), as well as the places where services are delivered (hospitals, private practices, federally qualified health centers, etc.)

As the number of cases in Hawaii increases, all elements of the health system will be placed under incredible strain and if our local outbreak goes unmitigated, the system will collapse under the pressure.

Extreme Measures

It is crucial to consider what health system collapse looks like to better understand why such extreme measures have been taken to slow the spread of the virus. A collapsed health system entails much more than people with the virus, and resulting disease, not getting life-saving health care. That is, it entails more than being unable to get into an ICU or onto a ventilator when a sick patient needs one.

These are terrible consequences in-and-of-themselves and have been cited repeatedly as explanations for the high case-fatality rates in places like Wuhan, China, as well as in Italy and Spain. In these places, the health system could not keep up with demand.

A collapsed health system is much worse. It means that when car accidents happen, or heart attacks, patients are directly competing for care with those needing treatment for COVID-19 infection. Similarly, it means women who need cesareans to deliver or children with asthma attacks are also competing for care, as health personnel, equipment and materials are redirected towards managing the outbreak.

It means that health staff exhaust and burn out, compromising the quality of care their patients receive. It means that providers are forced to make decisions about who can or cannot receive life-saving care, decisions that may haunt them for years.

As supplies for infection control dwindle, it means that care is provided under unsafe conditions for both patients and providers. The latter also means increased demands on a fragile health system as patients experience complications, such as secondary infections, and providers become sick and are removed from the workforce.

For all of us, it is imperative that we support all classes of health care workers and like many in the community already have, creatively seek solutions to the acute needs facing our health care staff (like insufficient PPEs).

Broader solutions for childcare and eldercare are also needed to assure frontline staff are able to focus fully on their jobs, knowing their loved ones are safe. As for the health care system, full mobilization of all resources under clear and undivided leadership is essential.

This last point is the most challenging, as the United States’ health care system is notoriously fragmented; nonetheless, it is probably the most essential for staving off some of the worst consequences of the outbreak.

Health crisis restrictions such as social distancing, which government and top health officials are implementing across the nation, stem from data gathered by epidemiologists. Those experts across the globe are analyzing stats from hospitals in countries slammed by COVID-19 to formulate how to control the virus’ spread.

Thomas Lee, an assistant professor of epidemiology at the University of Hawaiʻi at Mānoa, explained the trends epidemiologists are now looking at.

“Because China is five to six weeks ahead of where everyone else’s response is, (epidemiologists) are now able to utilize that and shift some focus on looking at what caused it,” said Lee.

He said epidemiologists are looking at population trends and COVID-19’s infection rate to develop an aggressive approach toward containing it. Lee explains one of the findings experts arrived at regarding testing.

“It’s going to be important as the virus spreads, and it’s going to spread to rural communities as well, how well we can screen all of our citizens. Not just the ones living in the current hotspots,” Lee said.

Like thousands of UH faculty, Lee is transitioning all of his courses online for the remainder of the semester. He plans to focus epidemiology lectures on COVID-19 studies that continue to surface as the outbreak grips the globe.

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COVID-19

As the number of COVID-19 cases surge in cities like New York, some in Hawaiʻi fear an exponential rise in the Aloha State is imminent. There is a statewide stay-at-home order in effect and practicing social distancing remains crucial to stem the spread. But ​Alan Katz​, an epidemiology professor at the University of Hawaiʻi at Mānoa, said ​because a majority of Hawaiʻiʻs communities are rural, it could help lessen the chance of a major outbreak.

“We only have one urban center in Honolulu and the rest of the islands are rural including any spot on Oʻahu that’s outside of Honolulu, that’s considered rural. So that’s good. People are less densely populated,” Katz explained. The UH Mānoa epidemiologist said it gives the state some leeway in minimizing the spread of the highly infectious virus.

Because the incubation period for COVID-19 is up to 14 days, Katz said Hawaiʻi will inevitably see more cases during the statewide lockdown but is hopeful it won’t be a steep increase. In order to avoid a major outbreak, he urges everyone to take health guidelines seriously.

“The most important thing you can do is maintain social distancing. Stay 6 feet away from each other. That’s going to really dramatically mitigate person to person spread of this. If you’re not essential, if you’re supposed to be at home try to stay at home. Don’t aggregate in groups,” Katz said.

According to researchers, ​COVID-19 is much more contagious than the seasonal flu.

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COVID-19

Aloha Public Health Students,

You should have received notification from University of Hawai‘i President Lassner about the move to online classes starting Monday, March 23 and the plan to resume in-person classes on Monday, April 13. His message, as well as information on the University’s response to COVID-19, can be found here: https://www.hawaii.edu/emergency/important-health-information-novel-coronavirus/.

You probably have many questions! Please know that the Office of Public Health Studies (OPHS) is actively engaged in contingency planning to support student learning and other key functions in response to COVID-19. To this end, the following information is being provided for your reference. However, as noted in President Lassner’s email, “given the extreme fluidity of the COVID-19 situation, this guidance is subject to change as the situation evolves.”

  • The UH Mānoa campus will remain open and housing, library, dining and recreation centers will continue normal operation. This includes OPHSAS and the OPHS Computer Lab. For now, the Hui Lounge will remain open to students as well.
  • You should expect to hear directly from your instructors about what to do for each class and the link to use to access their online courses.
  • Online classes may be synchronous (students and instructor online at the same time) or asynchronous (independent work) or a combination of both.
  • Zoom will be the platform most faculty will use in offering their courses online. Further instructions for using Zoom will be provided shortly. You do not need a Zoom account to join a Zoom meeting/class.
  • If you do not have access to a computer or high speed Internet, please let your instructor or advisor know. Note that a smartphone will work for Zoom.
  • OPHSAS has access to four (4) online Zoom “rooms” that we can use to schedule virtual capstone presentations and dissertation defenses should this become necessary. When not in use for online classes, students may request to reserve these Zoom rooms to meet virtually for group projects or capstone practice sessions through OPHSAS (ophsas@hawaii.edu) following a similar model to our room reservation system.
  • Students scheduled to graduate this spring will practice their capstone presentations online via Zoom in PH 789 to ensure you are prepared to use this format.  Doctoral students graduating this spring should coordinate with their committee chair or faculty advisor to arrange their dissertation defense and/or practice sessions via Zoom.  
  • Please check your email regularly for updates and communication on next steps as the situation continues to be reevaluated and assessed.
  • This uncertainty can be distressing. The following resources are available to you: 
  1. The University’s Counseling & Student Development Center (CSDC) offers support to all UHM students to assist with personal, academic and career concerns. All services are confidential and free of charge. For more information, you can visit the CSDC website or call (808) 956-7927. 
  2. For COVID-19 specific information, the World Health Organization offered the following guide: https://www.who.int/docs/default-source/coronaviruse/mental-health-considerations.pdf
  3. Or this from the American Foundation for Suicide Prevention (AFSP) office: https://afsp.org/taking-care-of-your-mental-health-in-the-face-of-uncertainty/

Travel

Stay Informed

Thanks to the OPHS Leadership Committee and the DSW leadership team for help in crafting this message! 

Tetine Sentell, PhD
Professor and Director
Office of Public Health Studies

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