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When Gov. David Ige delayed the start of Hawaii’s pre-travel testing program for the first time earlier this summer because coronavirus cases were spiking on the mainland and locally, there were 310 active COVID-19 infections in the islands.

Now, as state officials prepare to launch the controversial program on Oct. 15, Hawaii has more than 1,800 known active cases.

Lt. Gov. Josh Green said Hawaii should have invited travelers back to the islands in July. But he said Hawaii residents weren’t psychologically ready to revive the tourism industry at that time.

Now, Green said, the state is launching the program out of necessity. Hawaii workers are starting to lose their jobs permanently. Their savings are being depleted. Their health benefits are disappearing.

“We are reaching the point of no return,” Green said. “So we actually have to do a good job in preventing the spread and we have to reboot our economy. We don’t really have any choice.”

In three weeks, Hawaii will for the first time allow trans-Pacific arrivals to avoid the state’s mandatory 14-day quarantine with proof of a qualifying negative COVID-19 test.

Green said he anticipates Hawaii will see between 8,000 and 10,000 daily trans-Pacific arrivals by the end of 2020, up from an average of several hundred arrivals per day since the onset of the pandemic.

Yet as Oahu emerges from a four-week stay-at-home order that forced thousands of businesses to temporarily close again, some local doctors, researchers and former public officials question how effective one test will be in blocking the virus from entering the islands.

And the experiences of other tourism destinations that have reopened to leisure travel show it’s not so easy to reboot the economy without a surge in COVID-19 cases.

Officials with the Department of Health did not respond to questions about whether they support the pre-travel testing plan.

Dr. Jonathan Dworkin, an infectious diseases doctor who works with The Queen’s Health Systems said the plan doesn’t seem based on “sound epidemiological science” since one test may not catch a cohort of people who could still have the COVID-19 virus.

“A single, pre-travel test is likely to miss a large percentage of infected travelers,” he said.

JoAnn Yukimura, a former Kauai mayor and county council member who has been involved with local COVID-19 research, said she agrees that a one-test plan is risky.

“It’s not going to achieve the goal that those who are advocating the one test plan think it will achieve, because with that many infections coming in, we’re going to be headed for another shutdown, even with the most stellar contact tracing,” Yukimura said. “The way they’re reopening is not safe and it kind of gives me nightmares sometimes.”

But Green said residents shouldn’t be afraid.

“I don’t want people to be afraid. If it becomes dangerous in any way, we’ll reassess.” — Lt. Gov. Josh Green

State leaders are now in sync in their understanding of how to hamper the virus’ spread through testing, contact tracing and isolating people with active infections, as well as their close contacts, he said. And those leading the state’s COVID-19 response have begun to bolster Hawaii’s capacity to conduct testing and contact tracing.

The state’s hospital capacity has been augmented by hiring more than 200 traveling nurses who will work at 10 Hawaii hospitals over the next two months. And a new data dashboard unveiled by the DOH is providing the public with more detailed information about the status of the virus and the prevention methods.

What’s more, Green said thousands of travelers are already coming into Hawaii without a test. The pre-travel testing program, he said, should be viewed not as a foolproof policy but as another layer of protection.

But even officials who support the plan say the state will need to do a better job of communicating with visitors and the public to make Hawaii’s reopening strategy a success.

How Pre-Travel Testing Works

Hawaii’s new pre-travel testing program is still under development, but here’s what we know so far.

Qualifying tests must be , also known as NAAT — a molecular test that requires a minimally invasive nasal or throat swab or saliva sample. If test results are not available at a travelers’ time of arrival to Hawaii, that person will have to remain in quarantine until they get their test results. Only after they receive a verified negative test result will they be released from quarantine.

Travelers will be responsible for the cost of their test, which must be taken a maximum of . The cost of a test ranges between $120 and $140, according to Green. Tests will not be available at the airport.

The state has agreements in place to facilitate the pre-travel testing program on the mainland with CVS and Walgreens, Kaiser Permanente, and a physician and urgent care network in Oregon called AFC.

The state has also approved tests that Hawaiian and United airlines will offer to passengers before they arrive at the airport. Green said a partnership with another major U.S. airline is forthcoming. International travelers who can show proof of a qualifying test will also be able to skip the 14-day quarantine period.

State leaders predict travelers will make longer trips due to the hassle of pandemic travel. And those who do come, Green predicts, will be conscientious travelers.

Green also said he expects only a small portion of incoming travelers will land in Hawaii airports without first obtaining a qualifying negative test result.

“I don’t want people to be afraid,” Green said. “If it becomes dangerous in any way, we’ll reassess. But I think it’s time. We’ll be as safe as we can be.”

Once travelers arrive, they will have to show proof of their test results and fill out the state’s digital “Safe Travels” form. The form collects health and contact information to assist in public health monitoring.

It’s an added safeguard in a system that includes automated temperature checks and screening for people with symptoms or temperatures of 100.4 degrees or higher.

“A lot of us have real concerns and fears of another surge.” — Daniel Ross, president of the Hawaii Nurses Association

The Safe Travels app will indicate when a traveler has cleared the pre-travel testing program. The traveler can then display that clearance to hotel and restaurant workers or drivers for ride-hailing companies like Uber should they request it.

Green said the state will have a list of travelers who do not qualify to bypass the 14-day quarantine, as well as their lodging location and contact information. He said the state will be able to police quarantined travelers by visiting their hotel rooms to follow up on reports of violations.

Those who must quarantine must do so at their own expense. That includes any traveler who tests positive for COVID-19, as well as their travel partners.

“I think our bigger challenge is that right now, a lot of people are scared to travel in general,” Green said. “And a lot of people are out of work, so they might not have resources to travel.”

Questions Surround One-Test Efficacy

Critics of the plan — many of whom are medical experts — say one test isn’t reassuring: they fear people who caught the virus right before or after traveling en route to Hawaii means they’ll either be most contagious during travel or after they arrive in the islands.

�ճ󲹳�’s depends on how far the illness has progressed. An estimated 45% of infections are spread by carriers before they develop symptoms.

Honolulu emergency physician Dr. Darragh O’Carroll called even the most sensitive tests “practically useless” if conducted during the first couple of days after someone contracts the virus.

Instead, he and other Hawaii medical and research experts have advocated testing travelers at least twice: before and after they arrive to catch any infections that may have been missed by a test taken prior to travel.

What is Fault Lines?

“Fault Lines” is a special project that explores disruption and discord in Hawaii and what we as a community can do to bridge some of the social and political gaps that are developing. .

A group of Kauai-based doctors, scientists and former public officials including Yukimura and virologist John Alderete formed the Kauai COVID-19 Discussion Group and teamed up with a biostatistical modeling expert from the University of Washington to .  Their study has not yet been peer-reviewed, but it concludes that two tests within six days of each other would be more effective.

“With a two-test strategy, the infections drop dramatically if the test is done on the seventh day,” Yukimura said. “We actually have a plan which is much safer and reduces the quarantine to a seven-day quarantine. It still has infections that come in undetected, but it’s much less.”

Green, however, said the state doesn’t have the capacity to give thousands of travelers a secondary test. Even if it did, Green said he expects that the number of positive cases caught by a secondary screening would be “extraordinarily low.”

While the number of new daily COVID-19 cases appears to have plateaued, hospitals across the state are still overwhelmed. The state has spent $14 million in federal coronavirus relief funding to hire a team of 230 travel nurses and respiratory therapists to help hospitals care for COVID-19 patients for the next two months.

The thought of more cases associated with travel is worrisome, said Daniel Ross, president of the Hawaii Nurses Association.

“Right now there’s a lot of anxiety over the unknown because there are nurses getting sick with COVID, and we don’t know exactly how many because management hasn’t come out with information yet,” he said. “A lot of us have real concerns and fears of another surge.”

A two-test program would provide a little more security, he said, though, “Nothing’s going to be foolproof.”

How Other Destinations Are Bringing Back Tourism

Alaska, another tourism-dependent state, has a comprehensive pre-travel testing program similar to the one Hawaii is on the verge of launching.

In June, Alaska became the first state to allow visitors to avoid quarantine with a negative COVID-19 test.

Travelers whose tests were taken up to five days before their flight landed in Alaska were instructed to take a second test at the airport and minimize their interactions until the results came back. Those who arrived with no pre-test could get a test at the airport for free. And those who did not wish to get tested could opt for a 14-day quarantine.

Unlike Hawaii, Alaska was not so severely affected by federal testing kit shortages. The state used to assemble that has been critical to the success of its pre-travel testing program.

Alaska currently administers 3.9 tests per 1,000 people, whereas Hawaii administers 1.0 tests per 1,000 people, according to .

In the program’s first five weeks, Alaska screened more than 78,000 people at its airports, yielding a total of 134 positive cases, according to Dr. Anne Zink, Alaska’s chief medical officer.

But by mid-summer, Alaska was experiencing a surge in positive COVID-19 cases. On July 26 the state, which has a population of roughly 731,000, reported a record 231 cases — with 186 Alaskans and 45 nonresidents diagnosed.

So in August the state revamped its pre-testing travel program. It closed the pre-travel testing window from up to five days to a maximum of 72 hours. And it started requiring nonresidents arriving without a pre-test to get tested at the airport for a $250 fee. Residents returning home could get free airport testing or opt for a 14-day quarantine.

The city of Anchorage imposed , requiring travelers to undergo a second round of testing a few days after their arrival in order to be able to eat out at restaurants.

In September, Alaska’s infection rate has receded slightly to an average of about 78 new cases a day. The state has among the lowest COVID-19 death rates in the nation. But triple digit daily case numbers are no longer uncommon.

Things didn’t work out so well for French Polynesia, another tourism-dependent destination that implemented a program similar to Alaska’s.

French Polynesia opened in July to international travelers who could display results from a recent negative COVID-19 test. After four days, travelers to French Polynesia had to take another self-administered test.

Despite the government’s decision to institute a second test, French Polynesia experienced a sharp spike in COVID-19 cases that ultimately gave rise to community spread.

From March to June the country recorded 62 positive COVID-19 infections. Six weeks after the nation reopened its borders to travelers, there were more than 1,200 infections.

Most of the new cases were in urban Tahiti. But infections started popping up on some remote islands that hadn’t previously detected any positive cases.

The government reacted by banning large gatherings, closing down nightclubs and requiring mask-wearing in restaurants. Several schools in Tahiti temporarily shut down. But a surge in coronavirus infections has continued despite these .

The island nation of 280,000 people now predicts it will have by year’s end.

Better Communication Needed

Some public officials say Hawaii needs to move quickly to ramp up its strategy for communicating with visitors and residents to ensure that a pre-travel testing program will go smoothly.

House Speaker Scott Saiki said incoming tourists must know what will be expected of them during their Hawaii vacation.

Will visitors be allowed to gather in groups? Where will mask-wearing be required? Will restaurants be open for indoor dining? Once they clear the pre-travel testing program, will travelers be permitted to fly from one island to another without having to quarantine?

Once the rules are developed, how will the state ensure they are plainly communicated to travelers arriving from different states and countries? And how will they enforce them?

These are details that the state still needs to figure out.

“It’s critical that we keep to the Oct. 15 reopening date,” Saiki said. “We cannot deviate at this point so between now and then we need to make sure that all of our protocols are in place and that everybody understands what those protocols are.”