New virus cases likely the tip of the iceberg

The story about the visitor to Kaua‘i who tested negative twice — on the pre-travel test and the voluntary post-arrival COVID test — but then turned positive days later (TGI 10/29) was not unexpected. It was predictable.

This is because the incubation of the coronavirus often takes four to 10 days from the initial infection before it will show up on tests. Additionally, the patient could have become infected before or after the first or second test, especially since no quarantine was involved.

The big question now is: How many other visitors and returning residents with COVID-19 are slipping into Kaua‘i and the state undetected and spreading the virus?

Since the one-test reopening, the frequency of new cases on Kaua‘i has increased noticeably. It is good that Kaua‘i County is providing voluntary post-arrival tests, but because so few of the visitors and returning residents are taking the tests, the new cases are likely to be the “tip of the iceberg.”

Over the week of Oct. 30 to Nov. 5, Kaua‘i County identified eight infectious travelers (four visitors and four returning residents) and one resident infected by a traveler. When the eight infected travelers are measured against the weekly average of 3,836 travelers arriving on Kaua‘i, we are already identifying twice the estimated one-infected-traveler-per-1,000 our state leaders use to justify the single-test reopening plan. Notably, at least three of these travelers actually tested positive on pre-travel testing but results were not provided until after arrival.

With only 2% of the visitors and 20% of returning residents volunteering for a second test, scientific data ( suggests at least two to three times more infections have entered our island undetected.

A more-accurate way of detecting the virus coming in with travelers and protecting our community is the protocol of a PCR pre-travel test, a six-day quarantine, and release on the seventh day based on a second negative PCR test. Such a plan was proposed in mid-June of this year.

Instead, the state and counties reopened with a scientifically-questionable, one-test plan, welcoming travelers from the continental United States where COVID is surging in many jurisdictions.

The reopening plan is putting everyone at risk — hotels, visitor-industry workers, businesses, families and schools. If the travel-related infections create a surge, it may be too late to prevent another shutdown.

It is urgent and important that Kaua‘i reopen, but we must do so SAFELY — not only to protect our community but also to achieve sustained economic recovery.

Economic recovery will not come if we compromise safety. Sustained economic recovery will only happen if we make safety a priority, as Mayor Kawakami has striven to do thus far. As economist Paul Brewbaker said, ”The epidemiological problem is the economic problem. You don’t solve the economic problem until the epidemiological problem is solved, until we mitigate and contain spread of the novel coronavirus.”

If Mayor Kawakami would go back to the governor and propose the six-day, shortened quarantine and two-PCR-test protocol mentioned above, citing the unfolding data on Kaua‘i, a lot of Kaua‘i residents would back such a courageous and innovative move — a move that will keep Kaua‘i the safe, COVID-free, economically-sustained kipuka it can be, like New Zealand. Such a proposal would likely find favor with the new Department of Health director, who has acknowledged the increased safety of a two-test plan.

It will be better than a shutdown. And, as visitors adjust and a new vision for tourism emerges, the visitor industry will grow stronger — just as all of us have changed and evolved to keep ourselves, our loved ones and our community safe and well.


Robert Weiner, MD, is a retired, board-certified general surgeon who worked at Wilcox Medical Center and Kaua‘i Veterans Memorial Hospital. He and his wife Linda Weiner started and operated the Kalaheo Clinic for 28 years. He also worked for Kaua‘i Hospice, where he continues to volunteer. JoAnn Yukimura is a former Kaua‘i County mayor and councilmember. She helped to start The Kaua‘i Bus and Kaua‘i Island Utility Cooperative, and was instrumental in stopping high-rises on Kaua‘i.

  1. Steve O'Neal November 8, 2020 1:56 am Reply

    There is no shame in making mistakes, only in failing to correct them. Mayor Kawakami, Dr. Berreman, please over-correct and get us back on the road. The way we have reopened is a mistake. We can do it right.

    Opening Kaua’i without a properly timed mandatory quarantine, without a second test, and without extensive surveillance testing in place, is a serious mistake.

    Kaua’i has 5% of the state’s population and on October 14th a miniscule .001% of the cases in Hawaii.

    And yet in the last three weeks you’ve accepted more than 10% of the state’s travelers and opened with the same protocol as Oahu which has 69% of the state’s population and 89% of the known cases. Put another way, on October 14th Oahu had more than a thousand times the cases on Kaua’i. Yet you allowed others to dictate that you open in the same manner.

    You invited travelers from high covid areas into your medically fragile 70,000 person community with the lowest covid case count in the US, and 99.9% of the world.

    An international story will soon be written as to how the neighbor islands allowed themselves to open like Oahu, by interests mainly on Oahu, and fully squandered their isolated location and covid free gift. Kaua’i will be the starkest example.

    With some imagination and targeted marketing you can bring thousands of high value longer term guests to the island. I’ve never seen a single article heralding Kaua’i’s incredibly unique virtually covid free status. Instead the most motivated ponder how to move to New Zealand.

    You have evidence from Alaska, Tahiti, the Bahamas, and other destinations that make it clear a single pre-flight test will let too much covid through and eventually result in community spread.

    Mayor Kawakami, Dr. Berreman, please protect your citizens and correct this error – before it is too late. I’m not sure you have a week.

    Mayor Harry Kim accepted that he was not forced into opening. and twice threatened to opt out. He brought the governor back to the table, and then in a moment of weakness which he now admits, accepted a nonsensical second test upon arrival. For many travelers it was hours after they took their first test. Mayor Kim’s only regret, as he stated last week, “I should have pushed harder.”

    Mayor Kawakami, Dr. Berreman, you can more safely open this island – but wisely and with some creativity. No more half steps. No more hoping for 2nd test participation when you see just only 2% adoption. Be leaders. We’ll support you. Don’t follow those who are not putting your citizen’s interests first.

    This is the most important game of your career. Please raise your game for all of us.

    1. John November 8, 2020 4:03 pm Reply

      As logical and eloquently written as your comment was, @SteveO’Neal, you tragically overlook one fundamental variable that nullifies all of your other points: Mayor Kawakami’s decisions are centered around immediate financial gains that bolster his position among his business-class donor base.

      Even if thousands of Kauai residents were to suddenly drop dead from Covid as a result of Kawakami’s horrible decisions, his re-election is all but assured because he will have the support of Big Airline and Big Hotel. Welcome to Hawaii Politics 101.

    2. Doctor Jack November 9, 2020 9:46 pm Reply

      There is no virus or organism that’s attacking or infecting people. The people who are dying are the same people that were gonna die before the covid thing was unfurled on the world stage. People die and they die every day everywhere so that’s just the way it is, nothing new about that. The tests are not tests so they are a moot point. Whatever comes out of our bodies is just waste matter and nothing to be alarmed over. Theres nothing going around and Fauci and Gates know it but when you’re painting a scenario that’s taking advantage of people’s fear of something they’ve been tricked into believing for a long time, and you’re trying to sell billions of dollars worth of vaccine.poisons as well as thinning the herd, you have to be professional about your lying cause the stakes are real high. Winner gets the world.

  2. Debra Kekaualua November 8, 2020 6:25 am Reply

    mAhalo Dr Weiner! 40+ years ago the kauai medical community (KMG) tippy-toed through the tulips and even then, Kauai grew to the risks that are today evidenced. As a medical professional, KMG were using the Physicians Exchange Emergency Call Center, Central Answering Service, which I was the sole proprietary owner and my team of 8 covered medical, YWCA rape crisis, AA/NA hotlines and dozens of other emergency communications including small businesses that could not afford a secretary. So we filled in that gap and provided Live voice 24-7-365 coverage. No Hawaiian Tel car phone, beepers or wifi cell phones had yet been made available. Through the investment via my then retired USAF intelligence officer dad, he purchased for the business to tower base-stations, 25-voice pagers and system. Dr. Weiners’ Clinic Kalaheo roof became a motorola paging tower site and WH was the other location that Central Answering service used to provide physicians island-wide, and contracts for emergency or on-call services was made with KMG and similar other necessary agents. Those days to now has become so vastly compromised by the retroactive voted in to power with so many questionable powerful personalities that it became impossible to move forward with any sense of integrity. It all became so convoluted with court judges, P.A. P.I., KPD five now six chiefs, Mayors, and department director peoples manipulations that much of the community was too busy to defend. My business and team was paying attention and to this day, we all have been put in a STFU box that completely has brought this USA system to its knees! NOW, that we are flat on the ground under the kauai bus, up against the airport curb, and the magnitude of the is what it is facts that continue to be thrown under the rug is the problem, and that, there are more corrupted collusionary hierarchy involved, it has come down to FBI/DEA investigations that clearly shows the cards are imploding, “guilty kealoha stolen mailbox fraud”, murder, and collusion across the board! The Covid problems is the sidestep plandemic and their are many other comrades I worked alongside with at WH, ER, Med Records, EMT, and even as a Kauai bus driver during fiasco gasgate. Recent vote and too many in denial or just plain disregard for truth and integrity has taken over, especially with Brun being set-up, when these same non-medical, tourism, and others continue to play God with our very lives! This is not about infections via transplanted, tourists, or return residents. This is about the heightened u.s. military, who continues their rampage at PMRF. TGI publishes USAF “settles” on Kauai. On C-span II 2018 video, military planning and finances received 1.2 billion dollars to build a 12-story Ballistic Missile Launch-Intercept facility on the “Mana Flats”. DLNR closed polihale indefinitely, not because “residents were behaving poorly”, but so that the military could take control as they have two Napali ridges then west south west to where the military gate entrance is going to be repurpositioned to McArthur Park, effectively keeping civilians out of their way for testing! The percussions, military F-22 Raptors touch and go Lihue airport stagings, Submarine activity, and huge ingress of military peoples who fire up these killing machines has successfully make Kauai a bulls-eye! The decades old “chaff” overhead as meteorologist, Guy Hagi that exists doesnt allow our island to receive a reasonable weather report, so it is all a no-brainer for this USAF brat retired, 50+ year resident and similarly the old time Physicians that also have witnessed the degredation. Yet pointy-fingers rehired via votes cast continues the ol’boy business as usual. Five decades past mayors carvalho, yukimura, kusaka, and past governors x5 have lined their pockets time and again, while we sit and rotate. What we need is RICO because it has been evidenced that FBI “Kenji” and all the back storied peoples are not investigating and are being olayed as we have all these same years. The guilty needs to fess up, get it corrected, or be in line to Pay to Play!

  3. nobody November 8, 2020 6:29 am Reply

    It does seem likely we are headed for another economic lockdown (the 14 day quarantine). The recent arrival of visitors has been a savior for many failing businesses.

    The cost of testing visitors multiple times is too high for the government to bear. Visitors will not tolerate a 6 day quarantine.

    I think the solution may be to somehow have multiple testing with the cost paid for by the visitors. The visitors not willing to pay this cost can wait until the pandemic is over. The ones that will pay for their testing may be enough for the Kauai to economically survive this period in relative safety.

  4. John Patt November 8, 2020 7:53 am Reply

    Yes to mandatory double tests. It would protect the residents, and also let the visitors know that they can enjoy their vacation COVID free, which is not the case now.

  5. Steve November 8, 2020 7:53 am Reply

    Here Here! Finally an educated, thoughtful plan.

  6. Deborah Nantais November 8, 2020 8:23 am Reply

    Please Mayor…put the people of Kauai First &listen to us ! We are all “concerned” about the influx of visitors &residents seeding us silently while most do not post test,thus spreading the
    virus all over the island!
    The current plan is NOT WORKING! Protect the people(and taxpayers) of this county&reinstate the quarantine &post test!

    Mahalo from a high risk Senior who is very concerned!

  7. Paulo November 8, 2020 8:29 am Reply

    We absolutely do need the 2 tests with a 6, or 7 day even better, quarantine in between. Most of us asked for that but the governor didn’t want different plans for each island.

    COUNT PROBLEMS: The count for Kauai reported in Mayor Kawakami’s article yesterday was 12. Later the 3 PM state COVID report came out which The Star Advertiser stated gave Kauai 3 additional new active cases. Shortly after that The Civil Beat reported Kauai’s 3PM new cases as 2. Why the discrepancy?

    Regardless 2 or 3 new cases reported in the afternoon on top of the 12 cases reported in the AM Garden Island by the mayor would be 14 or 15 cases. Today, one day later the front page of TGI still shows active cases at 12, recovered cases 63, total cases 71. What gives?

    1. Richard Stein November 8, 2020 12:17 pm Reply

      We acknowledge that there are some discrepancies between the data reported by the state and the county. It is most likely a timing issue in the reporting. Because of this we are basing our numbers off the county’s reporting on In this critical juncture of COVID infections, we will do our best to report the most accurate information given.

  8. Elaine Murphy, RN November 8, 2020 8:47 am Reply

    Thank you, Dr. Weiner for the sensible, science-based suggestion for a safer way to open Kauai to visitors and returning residents. Mayor Kawakami has exhibited superb leadership during the pandemic, but he has apparently been met by resistance from the governor’s office. The current rules are inevitably leading to severe consequences to our safety and economic recovery. We are headed for a complete shutdown with much suffering unless we follow the science. Please consider Dr. Weiner’s sensible suggestion. Time is of the essence. Thank you.

  9. peter November 8, 2020 9:56 am Reply

    Seriously ?!? You take the worst 5 days of data out of the available 20 and then use that data to justify a new traveler arrival plan ? A little biased don’t you think ?!?

    1. principle November 9, 2020 9:43 am Reply

      Would you select the best 5 days on which to base a protective plan?

  10. Diane Garrison November 8, 2020 10:31 am Reply

    You did not mention the 3 in hospital which will grow and is a particular danger for Kauai with its limited medical facilities. We support your position.

  11. Doug November 8, 2020 10:45 am Reply

    Good article, but it will not change any minds. Ige and Green function by deciding what they think is right and then continuing to walk off the cliff as it looms ahead (“no worries, the cliff will magically disappear, just keep walking”). We will either be shut down again in a month or so or they will let the virus rage out of control which is the same thing as shutting down because no one wants to vacation on Covid island. Then what happens to the economy??

  12. Susan November 8, 2020 10:48 am Reply

    I hope all the death and community collapse that is going to ravage Kauai the next several months was worth it to Mayor Kawakami and his Big Tourism buddies.

  13. Dr. Jim November 8, 2020 3:04 pm Reply

    I agree with the well thought out opinion expressed.

    Keep in mind if other locations are any indication, even if we were to shut down now, the trajectory of cases will continue to increase for about two weeks, and it will take around an additional 4 (6 total) weeks to return to the level they are at today. So we wont really be improving for over a month after we shut down again.

    I agree that recognizing that we have an emerging problem, and responding quickly may indeed save lives and protect our community. With the two test, 6 day quarantine restrictions we can have a level of tourism that will sustain the island for the next year, after which we can we return to a more robust tourism trade. If we consider the demand for working tourists who are looking for anywhere other than the mainland cities to work from remotely, I believe we can improve our economic outlook locally and generate significant income tax revenue ( remote workers are liable for taxes where they live- Hawaii).

    Perfect? No. But probably close to the best balance of care for our community, maintaining our medical system, not overwhelming our contact tracing system, keepong our schools open and safe for our keiki, and our kapuna out of harm’s way, and providing some inflow of income to the island. Please remember to step up and help those of our community that are more directly impacted by the diminished tourist trade, especially those that are without an economic buffer. Have empathy and compassion for those that are struggling financially and emotionally. These people, too, are the community we want to protect!

  14. mon November 8, 2020 4:16 pm Reply

    my friend is now in icu at wilcox,what does that tellyou,dealing with people coming,weather they live here or not,dangerous game we are playing, i wear my mask to protect you from me,so wear your maskto protect us,stay where you live and work from there,dont bring there here,save the people of kauai ..

  15. Linda and Chris November 8, 2020 4:26 pm Reply

    This is a very smart guest editorial with a sensible suggestion by two authors with exceptionally relevant Kauai experience. We residents should hope attention is paid and action taken.

  16. judi glass November 8, 2020 6:30 pm Reply

    Mahalo Jo Ann Yukimara and and Dr Weiner for this updated plan based on the numbers we are experiencing as the island allowed the testing in lieu of quarantine. Dr Berreman and Mayor please before it is too late, go back to our original plan. There would be nothing sadder than saying “I told you so’ and we never want that to happen. The Sunday NY Times had a big article about Hawaii tourism today in the main section called “Reopening is a boon for tourism but locals object” Full page story and we must keep our island safe. There can be no economic recovery with COVID taking a hold ( if it hasn’t already ) of our precious island. It is a tough situation but one that must handled right … we still have a chance. Mahalo

  17. MarilynHawaii November 8, 2020 8:42 pm Reply

    Mahalo Dr. Weiner., for best the perspective I’ve seen in TGI. We have entered a very troubling area of virus spread in the USA. If we all were interested enough to read how quickly virus is spreading on the mainland, and worldwide for that matter, we’d see that it’s moved into a new realm. We started with 2 cases nationwide. We are now at over 10 million.
    There are now cases of mutated virus jumping back and forth between mink and humans in Denmark. Covid is also found in minks in Holland, Utah and Wisconsin.
    I highly recommend searching YouTube for “corona virus in usa mink” if you’d like clear explanations and outlook. It’s very sobering.

  18. Robin November 8, 2020 8:53 pm Reply

    Everyone knew we needed a second test, but we weren’t listened too. Hopefully it’s not too late as covid is on our island. We need to require a second test with a quarantine. Our island will be valued as a safe destination and the people that come here will hopefully value our island and treat it with respect .

    3 of our 9 beds already taken and if we don’t change something quickly we will end up in total shut down mode again and in a lot more trouble.

  19. Margaret A Clark November 9, 2020 7:42 am Reply

    This plan suggested by Dr Weiner and Joanne Yukimura makes good sense, and should be implemented ASAP before things get any worse. Please !!

  20. Kauaidoug November 9, 2020 9:52 am Reply

    I myself have wondered about the motivations of the people wanting to visit and travel at this stage of the pandemic. I myself wouldn’t get on a plane unless it was life and death, not vacation. And the people who are willing to travel did they wear a mask in their day to day life? I have a suspicion that a lot of people willing to travel are not really convinced that this is a problem. Hard to believe but true. There was an article in TGI about some of the most infected counties in the nation voting for Trump! Our visitors are going to be among that number and we can’t have people coming here who manage to slip past our screening process.
    I guess what it boils down to is nobody, no institution, is going to put our needs first except us right here on Kauai so we need to get this right and right the first time and that opportunity, with months of postponement, has slipped past already.

    We must get this right or what we thought was a good thing was just a Trojan Horse for the virus.

  21. Rick Goddard November 9, 2020 2:07 pm Reply

    I’d like to post a visitor’s perspective. I’ve visited 15 times, so Kauai is very precious to me and see that losing any portion of the people, businesses, and culture is not worth cutting corners on testing. It appears the state of Hawaii did so in this case. What is a shame is that there is a reasonable solution at hand.
    My wife and I are planning to visit unless it seems it is the wrong time (it’s looking that way). But, I would do this and wish it was part of the plan from the beginning. We will take the test 8 days prior to the day of travel and then quarantine ourselves (no visitors, no outings except for food and the next test). Then, two days prior to travel, take the Hawaiian pre-travel test. This covers the incubation period prior to travel. Then, when we arrive and stay at our place for three days, take the final test in Lihue. Assuming all the tests are negative, we follow the rules which are quite similar to our home in Washington State. That first test and quarantine period is critical and should have been part of the state program. A similar type of testing sequence is required at hospitals prior to any scheduled procedure, why not do the same thing for travel to the islands? I don’t see the quarantine period after arrival doing much good in terms of sustaining businesses because most visitors are there for a week. They just wouldn’t come. The dual pre-travel test with self-quarantine would offer greater safety and assurances that visitors are not carrying the virus. No guarantees, of course, and it does rely on the visitors vigilantly do their self-quarantine faithfully, It’s either that or just lock up the island for travelers until the vaccine and treatments are able to protect the citizens.

  22. S Willis November 9, 2020 5:05 pm Reply

    Totally agree. It’s not working. Many visitors will not volunteer for the post test because it costs 150.00 per person if you are not a resident. That’s 600.00 for a family of four! (And that’s after the pre-test which can cost up to 250 per person.) Tests need to be free or no one will volunteer to take them.

  23. Do what’s right November 10, 2020 9:42 am Reply

    I agree with the testing and quarantine period mentioned in this article. I was surprised Kauai opened up tourists travel from all states with many states experiencing high cases. If the county officials main priority is to keep Kauai safe we need to change our quarantine and testing program. I feel so sorry for those on Lanai. It only took one person for COVID to cause so many cases. I hope Kauai isn’t headed in that direction in the coming days. I hope I won’t become one of those to get COVID.

  24. peter. November 12, 2020 9:36 am Reply

    No, obviously not. In fact an ethical statistician would take all the data available, throw out the bottom and top 1%, and then analyze the data.

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