key: cord-0691924-syr75q0i
authors: Miller, F. DeWolfe; La Croix, Sumner; Brown, Tim; Ramsey, L. Thomas; Morens, David
title: Unique pattern of COVID-19 infection in the State of Hawai‘i
date: 2020-12-01
journal: Int J Infect Dis
DOI: 10.1016/j.ijid.2020.11.201
sha: a76ee2add395726b91f36c04c0b8fe48c3cd3266
doc_id: 691924
cord_uid: syr75q0i

This is a brief report on an unusual observation regarding COVID-19 cases. The State of Hawaii is one of the most remote of the Pacific islands and the population is approximately 1.4 million. The racial and ethnic diversity is very high. For example, white Caucasians comprise ∼25%, Asians including Japanese, Chinese, and other Asians account for ∼30%, Hawaiians for 20%, and Pacific Islanders mostly from Micronesia and Samoa comprise ∼4%. We discovered that the COVID-19 rate in the latter group was up to 10 times that in all of the other groups combined and they accounted for almost 30% of cases. Moreover, we are unaware of COVID-19 transmission from Pacific Islanders to islanders with other ethnicities. Thus, there is an epidemic within the epidemic in Hawai‘i.

The State of Hawai'i comprises the most remote of the Pacific islands and it is currently experiencing an unusual coronavirus disease 2019 (COVID-19) epidemic within an epidemic. Hawai'i is an archipelago with a population of 1.42 million in 2019. Most COVID-19 cases have been concentrated on the main island of O'ahu, followed by much smaller rates on Maui, Kaua'i, and the Island of Hawai'i. The first confirmed case of COVID-19 was reported in a Hawai'i resident who returned to O'ahu on March 6, 2020. A sharp peak in COVID-19 cases occurred in March and April 2020, where 62% were attributed to returning residents and visiting tourists. On March 23, the State imposed mandatory 14day isolation on all incoming visitors and residents returning from the United States and foreign countries. Daily air passenger arrivals dropped to 1-2% of those in 2019. By April 23, the number of reported cases of COVID-19 decreased to less than five per day. Many non-essential businesses reopened between May 15 and June 15, and the stay-at-home order was lifted on June 1. However, COVID-19 transmission in Hawai'i rebounded at the end of July and peaked at the end of August. The City and County of Honolulu banned social gatherings on August 18, as well as adding a stay-athome order and closing non-essential businesses on August 27. In total, 15,003 cases were reported in the week ending October 30 (DOH, 2020).

Hawai'i's population is multi-ethnic, including large subpopulations descended from Asians, native Hawaiians, other Pacific islanders, and Europeans, as well as many recent immigrants, predominantly from Asia and the Pacific islands. The COVID-19 case rate per 100,000 for Pacific Islanders was 448 on July 17 and 7.5 times higher than the combined rate for all other non-Pacific Islanders (59.7/100,000). The COVID-19 rate in native Hawaiians (not included in the Pacific Islanders classification) was 52.5/ 100,000 and slightly lower than the rate in Caucasians at 63.0/ 100,000 (see Figure) .

Remarkably, the cumulative rate per 100,000 among Pacific Islander after July 17 increased during every 7-day interval to 2383/ 100,000 by September 4. On October 30, Pacific Islanders comprised 4% of the total population of Hawai'i but they accounted for 31% of the total reported COVID-19 cases (Figure 1 Anecdotal reports from local community health centers, which are the principal medical providers for Pacific Islanders, indicate that COVID-19 cases are concentrated among people from the COFA countries, who make up almost one-third of this group (Halliday and Akee, 2020) .

The median ages of members of the various Pacific Islander groups were between 18.5 and 23.7 years in 2013-2017, which were much lower than the median age of 38.6 years in the entire state (DBEDT, 2018) . The sex ratios for the larger groups are slightly above or below 1.0. Pacific islanders are less educated than the rest of the population and their per capita incomes were 30%-80% below the median for the remaining population of Hawai'i in 2013 -2017 (DBEDT, 2018 . They are more likely to work in frontline service jobs than the rest of the population, particularly in the tourism sector (DBEDT, 2018; DBEDT, 2020) .

The epidemic among Pacific Islanders in Hawai'i has not been mirrored by significant COVID-19 epidemics in the corresponding Pacific islands, except for Guam, the Northern Marianas, and French Polynesia. In particular, there is no evidence for COVID-19 transmission occurring between Pacific Islanders and non-Pacific Islanders in Hawai'i, i.e., an epidemic within the larger island-wide epidemic.

Local explanations for the high COVID-19 rates in Pacific Islanders have been inferred from observations that Pacific Islander households in Hawai'i tend to be multi-generational, thereby leading to crowded living quarters, which make physical distancing, isolating at home, and adhering to lockdown orders difficult, and these issues may increase COVID-19 transmission. Language barriers and cultural practices anchored in large group meetings, such as religious services but particularly funerals, may have also contributed to the observed high rates.

Specific measures are being implemented to reduce transmission in Pacific Islander communities in Hawai'i (Derauf et al. 2020) . Most Pacific Islanders (excluding native Hawaiians) in the United States do not live in Hawai'i but instead they live in the continental United States, and thus they should be monitored by public health officials for COVID-19 infections and elevated mortality rates (DBEDT, 2020; Derauf et al., 2020) .

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Figure 1. COVID-19 rates per 100,000 by date. Pacific Islanders are Blue dots