The state reopens to tourism today, waiving the mandatory quarantine for travelers who test negative for COVID-19 before their arrival. But there is still debate over whether the plan will keep Hawaii safe.
Travelers who take a COVID-19 test from an approved testing site 72 hours before arriving in Hawaii can skip the quarantine if they show a negative result. Those who don't receive their results by the time they arrive only have to quarantine until they show they tested negative instead of the full 14 days.
However, some doctors in Hawaii do not think the one pre-test will be enough to contain the virus.
Dr. Michael Schwartz is part of a group of doctors who see a problem with a single pre-test. A key issue is the time it takes for the virus to incubate and build up in someone before a test comes back positive.
“You won't pick up those people between the time of exposure and day four,” he said.
Schwartz is referring to a study that found a false negative from a COVID-19 test ranges between 67% and 100% during the four days prior to a person showing symptoms. The chance of a false negative drops considerably between day five and day seven -- the average time it takes for symptoms to show up.
Dr. Lee Evslin, another physician in the doctors' group, echoed Schwartz' concerns.
“If you take people and you do a single test on them, you're gonna miss at least 30%,” he said.
“Then you throw in the fact that if somebody does this test 72 hours prior to taking their trip, they could not have the virus at 72 hours, but they could catch it in the next three days . . . So [it] doesn't pick up anybody that could have gotten the virus after the test. Again, that just pushes those numbers up.”
The doctors want to see travelers quarantine for seven days and then take a second test.
State Health Director Libby Char said during a Oct. 7 press conference that the travel pre-test could catch anywhere between 20% and 80% of cases. However, a second test could help ensure that the majority of infected travelers are identified.
“It's really quite varied,” she said. “The second test, again, the data is not robust. Some places show that if the first test catches about two-thirds of it, that the second test would then pick up a remaining percentage so that you'd end up catching about 70 or 80% of disease coming in.”
Dr. Jerry Van Meter with the Hawaii Medical Association said HMA supports the state’s pre-travel test plan but agrees a second test would be better.
“If the resources, both financially and just in terms of the number of tests, were available we would very much support a test being done after arrival,” he said.
“We would leave it up to the infectious disease specialists to determine when after arrival would be the best time.”
Gov. David Ige is allowing counties to implement their own second test, if they pay for it. But there is no consistent second testing policy across the counties.
Hawaii Island is the only county that mandates a second test, which will be administered at the airport. It’s an antigen test which is less accurate than the traditional PCR test, but can produce results quickly, generally within about 15 minutes. Those who test positive on the second test will have to quarantine and take another PCR test.
Oahu will not have a second test right away, while Maui and Kauai will have voluntary second tests given around the third day of arrival.
Statewide, travelers do not have to quarantine while waiting for their second test results.
Dr. Paul Pottinger, an infectious disease expert at the University of Washington noted a second test, even with limits, is still better than nothing.
“If we could test people before they arrive and then about day seven, ideally with some kind of isolation, but if not, still try to test them at day seven,” he said. “That would get the majority of those people who would be at risk of transmitting the infection.”
Alaska is the only other state that has implemented a travel reopening similar to Hawaii’s, and its experience provides some lessons.
Dr. Bruce Chandler with the Anchorage Health Department noted that COVID-19 spread widely in communities after restrictions were lifted, and travelers are now less of a concern.
“At the same time Alaska opened up travel, they [officials] were also relaxing some of the restrictions. Bars and restaurants reopened and fitness centers reopened,” he said. “So we provided a local opportunity for the virus to move from person to person. It wasn't all because we opened up travel.”
In fact, he says now, about four months after reopening, few cases are travel-related while local case counts remain high.
That’s why Pottinger says Hawaii can’t keep safe by relying only on testing.
“Testing is good, more testing is better,” he said.
“No testing will ever be good enough to replace the importance of physical distancing, wearing a mask when people are out in public, especially when they're indoors.”
At the start of the pandemic in March, travel was the leading risk factor before community spread began to rise in April, peaking in August. According to the Hawaii Data Collaborative, just over 5% of Hawaii’s positive COVID-19 cases have been travel-related.
Lt. Gov. Josh Green estimates that the single pre-test will only miss one positive case in 1,000 travelers. He calculated that rate based on the .2% disease prevalence rate on the U.S. mainland.
However, Pottinger said the wildcard in the calculations is the rate of infection in particular states.
“There's a huge surge in cases, for example, in the state of Wisconsin, the state of New Jersey and other states here in the contiguous 48, that are really seeing a big increase in COVID-19,” he said.
“Infection rates have reverberations and implications for people in Hawaii. Because if those airplanes that are coming in . . . filled with more and more people with COVID-19, then we may see problems crop up even sooner.”
JoAnn Yukimura, former mayor of Kauai, believes even just a few extra cases could quickly overwhelm Neighbor Islands’ small health care capacity, including hospital beds.
“The Neighbor Islands do not have the health care resources that Oahu has,” she said. “Kauai has nine ICU beds and 15 ventilators. We will need them for other purposes besides COVID.”
The Healthcare Association of Hawaii, which represents hospitals, estimates 50 to 100 more COVID-19 hospitalizations a day statewide about a month after reopening, numbers it says it can handle for now.
Travelers from Japan will also be able to participate in the pre-travel test program, the governor announced. But the procedures have not been worked out as yet and the timeline for their arrival is unclear.
Coming tomorrow: HPR looks at the economic impact on Hawaii as the state reopens to tourism.