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As an emergency physician here in Honolulu, my home since I was six months old, I have witnessed on a daily basis how our cases of COVID-19 have climbed to unsustainable levels.

While our immediate attention should be focused squarely on flattening our curve, Hawaii is on the precipice of a truly monumental and historic public health decision. Our economic survival depends on inviting a massive influx of potentially infected visitors into our relatively insulated island home.

This decision strikes a palpable chord in the people of Hawaii, as 242 years ago the arrival of Captain Cook and Western Civilization similarly brought with it a host of communicable diseases that decimated the ancestors of our islands.

How to lift the mandatory 14-day quarantine for transpacific visitors is complex, wrought with everything from testing supply chain issues, the informatics hurdles of verifying the legitimacy of a pre-test result, where to house infected persons, to even defending the legality of requiring a pre-test or tests.

It’s no easy feat to align all the elements of a successful reopening, but after hearing of our state’s initial approach and subsequent delays without accompanying revisions, I continue to fear for the safety of our communities.

To begin with, the percentage of infected persons that one negative PCR test will catch 72 hours prior to boarding a plane, plus arrival temperature screening, has been over estimated. Our state leadership has cited that it will prevent 70% of the potential cases from landing in our islands.

They did not consider that during the first three days of the, on average, five days of incubation — the time from when somebody contracts the virus to when they exhibit symptoms — even the highly sensitive “brain-tickle” PCR tests are practically useless.

Unique Opportunity

Much like pregnancy tests take weeks to become positive, it takes three to four days after exposure for the coronavirus to increase to levels that even our most sensitive tests can detect, so requiring only one test prior to arrival will catch roughly 30% of potentially infected individuals, not 70%.

To put it simply, conducting visitor and returning resident surveillance by requiring only one 72-hour pre-test and on-arrival temperature screening was a great start, but it will miss all of those still incubating in the early phase of the disease, as well as many asymptomatic persons. Additionally, temperature screening can be easily thwarted with affordable medicines like Tylenol or Ibuprofen.

Organizations attempting to create COVID-19 bubbles, similar to what Hawaii’s goal should be, have recognized the downfall of screening for COVID-19 based on just one test. The NBA, NFL, NHL, and film industry require several tests to get into their bubbles, and regular tests to remain there.

If multiple testing is good enough for commercial industries, it is good enough for Hawaii. If reopening to tourism prior to available vaccinations is inevitable, re-testing everyone on arrival should be added to the transpacific protocol, as we must capitalize on Hawaii’s unique opportunity via the bottle neck of visitor arrivals at our airports.

On Aug. 26, Abbot Inc., a company I have zero financial interest in, released a novel 15-minute antigen test that has a sensitivity and specificity of greater than 97%; is a short nasal swab rather than the uncomfortable deep nasal swab; requires no special machinery; can be directly linked to a time stamped QR code that could be presented at local businesses — and costs just five dollars.

There are many other rapid antigen tests that cost less than $20, are accurate enough to detect when people are infectious to others, and because of an Aug. 19 relaxing of testing requirements by the HHS during a public health emergency, do not require FDA approval to be used as long as our state government or Department of Health deem them adequate.

Imagine a Hawaii where all arriving tourists don’t just get tested on arrival, but need to pay to get tested daily while they are here. A daily test conducted before tourists leave their hotel could be included in their room fee, and will remove 100% of all arriving infected persons. If spaced out less frequently to every three days, it will remove close to 90%.

Our public and economic health are now intertwined.

The basic premise is the more we screen our transpacific arrivals and returning residents, the more we protect the nearly 250,000 of us that work in the visitor industry, our essential workers, and thus our islands as a whole.

If we do not filter out potentially infected visitors by increasing their testing frequency, our numbers will exponentially increase within a month of re-opening and return us to where we are now, where I am treating multiple extremely sick persons from the same family in the span of one 8-hour shift, where our hospitals are full past the brim, where we are running out of room to treat even non-COVID-19 emergencies, and our businesses remain closed.

Our public and economic health are now intertwined. If we rely on the current status quo Hawaii will quickly return to a virus hotbed, negating any progress made during this painful lockdown to make us a desirable destination. The 72-hour pre-flight test was a good start but Hawaii needs to play more offense.

If we shore up our reopening plan, instead of just pushing it down the road, we can prevent our communities from suffering again. If reopening prior to vaccination distribution is inevitable, there is a better way to protect us all.

But we must set our bar higher than the first time around.