Gov. David Ige is looking at reimposing restrictions, including limits on indoor and outdoor gatherings, to try to dampen the surge in COVID-19 cases that’s threatening to overwhelm the state’s health care system. He’s expected to make an announcement by the end of the week.

“We are having to look at restrictions again,” Ige told Spotlight Hawaii on Monday. “We were hoping that the case counts would level off and begin to normalize, but we are seeing exponential growth.”

Ige said that any new restrictions would try to limit impacts on businesses. But if case numbers continue to climb, more aggressive measures may be needed, including changes to the state’s Safe Travels program.

In just a few weeks, Hawaii’s case count has grown to twice the highest level seen since the beginning of the pandemic, fueled by the highly contagious delta variant. In August 2020, the seven-day average case count reached a high of about 250 cases. The seven-day average case count now stands at 502, with 7.3% of all tests coming back positive.

There are 225 people hospitalized with COVID-19, according to Lt. Gov. Josh Green, compared with about 50 people a month ago. Among those currently hospitalized, 43 patients are in the intensive-care unit, whereas on July 8 there were just 10 people, according to state data. The number of patients on ventilators has climbed to 30, the highest it’s been since 2020 before the rollout of the vaccines. The great majority of patients in the hospital are unvaccinated.

Green, who is also an emergency room doctor, warned Monday that the state’s hospitals are filling up. “I had a guy with a heart attack this week on the Big Island, and we had no beds to transfer him to for many hours,” he said in a video he posted on Instagram urging residents to get vaccinated.

As case numbers have climbed, state officials and private-sector employers have increasingly enacted vaccine and testing requirements for workers. Five of the state’s major hospital systems are now requiring all staff to be vaccinated, as well as three of the state’s major banks.

Ige announced last week that all state and county employees must be vaccinated by Monday or undergo regular testing. The policy affects tens of thousands of residents throughout the state, including many unvaccinated front-line workers. The Honolulu Police Department has a 75% vaccination rate, and the Honolulu Fire Department has a 78% vaccination rate, according to figures announced on Spotlight Hawaii. The vaccination rate among the city’s emergency medical workers is 78% and falls below 70% for the city’s ocean safety workers.

Hawaiian Airlines, the state’s largest air carrier, announced Monday that it too would require its employees based in the U.S. to be vaccinated by Nov. 1.

“Safety is the foundation of air travel, and it is ingrained throughout our operation and service. This is no different,” Hawaiian Airlines President and CEO Peter Ingram wrote in a memo to the company’s employees. “By getting vaccinated, we protect ourselves and those around us. That is malama.”

The Hawaii Medical Serv­ice Association, the state’s largest insurer, said Monday it is joining other local and national health organizations in requiring their employees to be vaccinated. HMSA said the vaccine mandate is a condition of employment for all employees as well as for any vendors or contractors who come into contact with HMSA’s workplace, workforce and members.

Top state state officials previously believed that achieving a 70% vaccination rate could be enough to achieve herd immunity, a level of vaccination that largely prevents the virus from spreading. With the delta variant, the threshold could be as high as 85% to 90%, according to Tim Brown, an infectious-disease modeler and senior fellow at the East-West Center.

The dramatic rise in cases in Hawaii comes as residents grow weary of restrictions that have now dragged on for a year and a half and residents adopt increasingly polarized views on vaccines and masks. Hundreds of residents on Maui and Oahu have protested the recently announced vaccine mandates in recent days.

The surge has caused a sense of whiplash as the state pivots away from reopening to increased restrictions and cases pop up throughout the islands. Nearly half of all students at Ka‘ohao School, an elementary school on the Windward side, have been asked to quarantine, KHON reported this weekend, and state officials say increases of cases in schools are inevitable.

“Fundamentally, we are in a much more dire state than we have ever been in before, throughout the COVID pandemic,” said Brown.

The delta variant of the virus is “burning through” the approximately 40% of Hawaii’s population that still isn’t fully vaccinated, said Brown, and the risk of being infected with the virus is now much higher.

“Delta is so much more infectious that if you are not wearing a good-quality mask and if you are not wearing your mask in all settings, basically, where you are potentially exposed to the virus, chances are you are going to contract it. It’s that contagious,” said Brown.

Brown recommended double masking or wearing N95 masks, which are much better at filtering airborne particles.

Vaccinated people also have a higher chance of contracting the delta variant, meaning they can also spread it, though the vaccine still provides good protection against being hospitalized or dying from the virus.

“People have to understand that the game has changed and their behavior has to change,” Brown said.

Brown acknowledged that it’s a hard reality to accept given that much of the population thought the state and country were heading toward the finish line, despite indications to the contrary as the delta variant ravaged other countries before arriving in the U.S.

“It’s traumatic,” he said. “Everyone thought we were seeing the light at the end of the tunnel. That’s no longer true with delta.”

State Department of Health officials Monday reported one new coronavirus-related death and 437 new confirmed and probable infections statewide, bringing the state’s totals since the start of the pandemic to 543 fatalities and 46,940 cases.

The new confirmed and probable infection count by island includes 293 new cases on Oahu, 56 in Maui County, 67 on Hawaii island, 16 on Kauai and five Hawaii residents diagnosed outside the state.