Hawaii is moving toward the next phase of the COVID-19 pandemic

As average daily coronavirus cases in Hawaii continue to fall, government leaders have announced the lifting of most restrictions and signaled that it’s time now to “live with COVID.”

The move marks a growing trend nationally as the outlook continues to improve, with daily cases in the U.S. having plummeted 90% from their peak during the omicron surge in January, along with declining hospitalizations and deaths.

Many are looking ahead at what they call the “next phase of the pandemic.” Now, leaders say, is time to move beyond crisis mode and return to a new normal, and to shift from government mandates to personal decisions.

Gov. David Ige echoed this sentiment at a news conference last week.

“You do not need an emergency proclamation to take precautions, and I think all of us have learned what we need to do to keep ourselves and our families healthy and safe,” said Ige on Tuesday. “All of us know the actions that we can take individually that make a difference for our community.”

Today, Hawaii marks the two-year anniversary of the first confirmed case of coronavirus in the state. On March 6, 2020, Ige confirmed a Hawaii resident who went on a cruise tested positive for the virus after returning to Oahu.

Two days prior, Ige had issued his first emergency proclamation in response to the pandemic, which would then be followed by a stay-at home order and mandatory 14-day quarantine for all travelers entering Hawaii.

More proclamations would stretch on for another two years to the current one, which remains in place through March 25.

After that, Ige will end quarantine requirements for travelers to Hawaii by letting the state’s Safe Travels program expire. All county-level pandemic restrictions have also been lifted.

Hawaii, which has logged more than 237,000 cumulative cases of the coronavirus, has the lowest number of cases per 100,000 residents of all U.S. states, according to the New York Times database. The state is also near bottom for total COVID-19 deaths nationwide — with a toll of 1,353 as of Saturday.

The 7-day average of new cases Saturday dipped to 165, well below 200, a low not seen since early December, according to the Hawaii Department of Health, and the statewide positivity rate fell to 2.5%.

‘Living with the virus’

Living with the virus is an acceptance that the virus is here to stay, as some experts have concluded. But living with the virus will mean something different for every person, depending on their age, health status, family circumstances and perception of risks.

“We’re in a new place, we really are,” said Keri Althoff, an epidemiologist at Johns Hopkins Bloomberg School of Public Health. “We know how to prevent severe disease for the majority of folks. We’ve learned a lot about how to protect people from severe illness and death.”

Althoff said it is incredible how much scientific information on COVID-19 has been amassed in just two years, and that vaccines are now available, which puts the U.S. in a different place than previously.

Pia MacDonald, an infectious disease epidemiologist at RTI, a nonprofit research institute, agreed.

“We have an effective vaccine, we better understand which therapeutics work and we’ve developed new therapeutics,” she said, “and we’ve gotten more used to other interventions such as improving air exchange and ventilation, masking and physical distancing when and where it’s needed. So it’s a very different time, and that’s why we can talk about it in a very different way.”

The U.S. Centers for Disease Control and Prevention recently made a major shift to the “living with COVID” approach when it released new metrics focusing more on hospitalizations than case rates, showing most Americans resided in counties with risk levels not requiring masks.

The CDC noted Friday that more than 90% of the U.S. population now lives in a community with a low (green) or medium (yellow) COVID-19 risk level and does not need to mask. Indoor masking in public is only recommended for communities with a high (orange) level of risk.

All of the Hawaiian Islands were green on Friday, indicating low levels of risk.

A growing number of Americans want to move beyond restrictions, according to a recent Axios/Ipsos poll, which found two-thirds agreeing the country is moving toward a time when COVID-19 won’t disrupt daily life.

More than half, 54%, support federal, state and local governments lifting all COVID-19 restrictions, compared to 44% in early February. One in four say they have already returned to their normal, pre-COVID-19 life.

Still, experts say those who are immunocompromised, live with family members with health conditions or live with children under 5 not yet eligible for vaccines, may want to continue being cautious. There are also many still struggling with long COVID-19.

And COVID-19 has had a devastating impact on many.

“On a very sad note, we have lost almost 1 million Americans to COVID in two years, and that is devastating,” said Althoff. “I think we have to be very mindful as we talk about living with COVID that there have been families that experienced tremendous loss during this time.”

It is not over

Although the omicron surge for the U.S. is over, the pandemic itself is not over.

Health experts continue to keep an eye on the omicron subvariant, BA.2, which is believed to be more contagious, and which has now been detected in all U.S. states.

DOH’s Laboratories Division first found it via whole genome sequencing in January, and in its latest variant report confirmed 54 cases of BA.2 in the state, up from 29 in mid-February.

Despite the CDC’s new guidance, Ige remains firm on his decision to keep the state’s indoor mask mandate through at least March 25, and possibly longer as he monitors the situation. Hawaii remains the only U.S. state to keep its indoor mask mandate in place with no announcements on when it will end.

While Ige has critics for holding out, he also has supporters.

“I think the problem we’ve got in this country is we’re incapable of taking a nuanced, gradual approach to anything, and it’s a problem,” said Tim Brown, an infectious disease modeler at the East-West Center in Manoa. “It’s either masks on or masks off.”

The transition could be gradual, he said, with the message that people should still consider masking up if they are in particularly crowded, indoor settings.

Althoff said waiting another 25 days when other places have announced plans to drop mask mandates for early or mid-March is not something “anyone can be too overly critical of,” given the time frame.

But she said it makes sense to be responsive when case counts go down as well as when they rise.

“When the numbers change, we’ve got to be responsive to it,” she said. “If you don’t follow those numbers when they look good, you don’t have credibility to start scaling up when numbers don’t look good.”

Flexibility is key, she said, and will continue to be moving into the next phase of living with COVID-19.

On the horizon

There will likely be more coronavirus variants on the horizon, according to experts.

“The fact we’ve had these different waves — the delta wave and then the omicron wave — there’s absolutely no evidence that we’re not going to have another wave,” said MacDonald. “In fact, we’re pretty much all expecting there will be new variants that cause new surges.”

While the U.S. might have the tools to manage the coronavirus as it does other viruses, including those such as influenza or the norovirus that ebb and flow, other countries with more limited resources are not as fortunate.

This coronavirus has also proved to be unprecedented in many ways, she said. It has shown there can be repeat infections with a different variant, and the emergence of new variants means they can occur non-seasonally.

Brown said the next mutation is not necessarily going to be less virulent.

“The reality is there’s nothing in the biology of the coronavirus that says it will mutate to milder forms,” he said.

Given that about 35% of the world population has not yet received a vaccine dose and remains at severe risk, there is still potential for the coronavirus to continue replicating and mutating.

Variants are a game of probability, said Althoff.

“The more viral replication, the more mutations,” she said. “The more mutations that occur, the greater likelihood of a variant that emerges, and we have seen these variants emerge kind of one after another.”

It’s important to work toward getting the whole globe vaccinated, and to continue monitoring human as well as animal populations for new variants.

Brown said Hawaii needs a solid surveillance system, including wastewater surveillance, to monitor transmission levels, and a detailed state plan for the next potential surge.

Also, the state’s push for vaccinations should continue, he said, with an emphasis on boosters, given that the initial vaccines wane over time.

DOH does not have a formal wastewater surveillance program in place yet, but said it has invested in equipment using federal grants and is just getting started with testing.

Gov. Ige said the state has increased its COVID-19 testing capacity nearly tenfold since the beginning of the pandemic and that plenty of at-home rapid tests are now available and covered by insurers.

President Joe Biden has announced plans to launch a “test to treat” program providing free antiviral pills at pharmacies for people testing positive for COVID-19.

As of Friday, about 77% of Hawaii’s population of approximately 1.4 million had completed the primary series of COVID-19 vaccines, while 38% had been boosted, according to DOH data.

Looking back, Ige said the biggest challenge at the start of the pandemic was having “virtually no information” about the coronavirus, along with no known treatment or vaccines.

“And finally, the fact that there was no playbook,” he said Tuesday. “The world was not prepared for a worldwide pandemic that affected virtually every country, every state in this nation — and every community was affected by COVID.”

Ige said he was most proud of how Hawaii’s communities responded.

“I was amazed that everyone was willing to do their part,” he said. “We understand what makes Hawaii special, and it is about the people and culture of all of us here coming from diverse backgrounds, always understanding there is a bigger reason to be willing to sacrifice individual needs to benefit the community. And over and over again, we were willing to do that, and that is why we have among the lowest per capita rates of infection and deaths in the country.”

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THE COVID-19 PANDEMIC IN HAWAII

2020

March 4: Gov. David Ige declares a state of emergency, which allows Hawaii to use funds to act quickly to contain the spread of the virus.

March 6: Hawaii records its first case of the “new coronavirus” in a resident.

March 17: Hawaii confirms its first community case, a tour guide at Kualoa Ranch with no recent travel history.

March 25-April 30: Hawaii’s statewide stay-at-home order goes into effect, and is later extended through May 31.

March 26: Mandatory 14-day quarantine for all travelers to Hawaii begins.

March 31: Hawaii reports the state’s first COVID-19 death, an older Oahu man recently hospitalized with medical issues.

Sept. 15: Former Department of Health director Bruce Anderson retires. Dr. Elizabeth Char serves as interim director.

Oct. 15: Hawaii launches pre-travel testing program to bypass the state’s mandatory 14-day quarantine. Later referred to as “Safe Travels.”

Dec. 10: First positive case of COVID-19 at Kalaupapa Settlement in Kalawao County on Molokai confirmed. Kalawao was the last county within the U.S. with no confirmed positive COVID-19 cases.

Dec. 15: Queen’s Dr. Lester Morehead is the first in Hawaii to receive a COVID-19 vaccine.

Dec. 17: Ige reduces mandatory quarantine for travelers to 10 days instead of 14 days.

2021

Jan. 18: Hawaii Pacific Health opens mass COVID-19 vaccination clinic at Pier 2 for kupuna ages 75 and up. Queen’s opens a clinic at Blaisdell Center on Jan. 25.

March 15: DOH opens COVID-19 vaccines to essential workers and Hawaii residents ages 65 and up.

April 15: Hawaii hits million-mark milestone in COVID-19 vaccine shots.

April 20: Eligibility for COVID-19 vaccines open to all residents ages 16 and up.

April 29: Hawaii’s first child fatality reported in a boy (under 10) visiting Hawaii with his parents.

May 12: Hawaii administers vaccines to children ages 12 and up.

June 14: DOHconfirms delta variant in isles.

June 15: Hawaii’s interisland travel quarantine no longer in effect.

June 25: Delta variant detected in all four major counties.

Aug. 20: The Queen’s Medical Center-West Oahu declares internal state of emergency due to influx of COVID-19 patients.

Aug. 29: Record one-day high of 1,678 coronavirus cases, but includes backlog.

Sept. 13: Honolulu’s Safe Access Oahu program begins, requiring proof of vaccination or a negative COVID-19 test to enter restaurants, bars and other establishments.

Oct. 15: Honolulu Zoo’s male lion, Ekundu, age 13, dies after testing positive for the coronavirus.

Nov. 3: First COVID-19 vaccines administered to keiki ages 5-11 at Kapiolani Medical Center for Women and Children.

Nov. 20: Hawaii surpasses 1,000 coronavirus-related deaths.

Dec. 2: DOH announces Hawaii’s first confirmed case of the omicron variant in an Oahu resident with no travel history.

2022

Jan. 3: DOH reduces COVID-19 isolation and quarantine requirements to five days, instead of 10, per CDC guidelines.

Jan. 10: The Queen’s Medical Center-West Oahu declares internal state of emergency due to staffing shortage. QMC-Punchbowl follows suit two days later.

Jan. 14-29: Overwhelmed by the volume of tests, Hawaii Department of Health puts a pause on processing negative test results and posting the state’s positivity rates.

Jan. 18: DOH reports a record single-day high of 6,252 new coronavirus cases during omicron surge.

March 5: Safe Access Oahu ends at 11:59 p.m.

March 25: Safe Travels Hawaii to end at midnight.