Effective Pandemic Response: Lessons from Kauai

Unified Command

The county's Emergency Operations Center (EOC) activation level increased steadily from mid-February 2020 until full activation with the first Kauai cases in mid-March. By early March, the county implemented an IMT with representation from county, state (including KDHO and the Department of Education), and private sector partners. Unified command included the district health officer and a county fire chief as co-incident commanders, and the KDHO public health preparedness planner as the co-operations chief, with a county department head. Unified command involved both county and state staff in leading a county emergency response, which was novel for Kauai.

Throughout the early months of the pandemic, the multiagency IMT met daily for incident briefings followed by detailed discussions by subject matter experts in response planning, operations, logistics, and finance. The IMT brought consensus recommendations to the mayor, to be enacted at the county level. The mayor attended the EOC daily briefings, as he would for any countywide emergency response, which enabled frequent real-time communications among the mayor, the district health officer, and IMT leadership during the rapidly evolving pandemic.

As the lead policymaker in the county, the mayor generally accepted IMT recommendations and enacted policies and regulations accordingly. The collaborative and mutually respectful working relationships in the IMT provided broad and deep support to the mayor in making the difficult policy decisions discussed in the following sections. The team collectively put the lives and safety of the people of Kauai County first.

Early Protective Measures

Kauai did not take a “zero COVID-19” approach. However, due to limited resources and geographic isolation, acute awareness of the county's vulnerability led to early protective measures before case counts rose. In March 2020, protective measures enacted included campground closures, nighttime curfew, stay-at-home orders, ⁷ and mandatory post-travel quarantine. ⁸ In April 2020, Kauai County enacted a mask mandate, the first in the state. ⁹ Together, these measures helped delay the vast majority of cases until late 2021, when many had been vaccinated and the less lethal Omicron variant predominated. Kauai was thus spared the mortality impacts and strain on the healthcare system experienced in much of the country.

Although these measures were controversial in Kauai County, as they were nationwide—with some considering them too much, too soon, and others considering them too little, too late—these early actions were recommended by the IMT, aligned with public health recommendations, and were generally received as painful but necessary measures implemented for the good of the whole.

Houseless Encampments

With campgrounds closed and a curfew in place, the county designated its campgrounds as safe shelters for the houseless community, serving that function for more than a year. Houseless residents were provided permits to shelter in place at a designated campground, with total occupancy rates set by the IMT to allow for adequate physical distancing. Structured camps for the houseless community facilitated subsequent testing, vaccination, provision of social and healthcare services, and educational outreach by public, private, and nonprofit partners. Federal COVID-19 funds were used to provide grants to organizations and restaurants to provide daily hot and cold meals. A trailer providing hot showers was made available 1 to 2 times weekly at each campsite, also with federal funds. Through timely notification by camp leadership of ill or exposed residents, KDHO promptly assessed the need for off-site isolation or quarantine, arranged testing for camp residents, and assisted with accessing healthcare when needed. This approach prevented large outbreaks among houseless individuals, who are often at risk of poor outcomes due to underlying health conditions.

Once vaccines and therapeutics were readily available to all, the county began a 3-month transition of the campgrounds back to recreational use. Declining community support for the program due to rising disturbances related to drug use, property damage, and domestic disputes, along with competing demand for this recreational resource, necessitated this transition. The county's housing agency and private and nonprofit partners made regular visits to the camp during the transition period to link residents to available resources such as the Housing Choice Voucher Program (Section 8), ¹⁰ COVID-19 rental assistance, and recently completed transitional housing units funded jointly by the state and county.

Prior response experience and preexisting relationships among partners created a strong foundation for this innovative approach to the houseless community during the pandemic. Although they were not long-term solutions to the growing problem of houselessness, they protected Kauai's houseless community during the critical part of the pandemic when vaccines and therapeutics were not available.

Community Needs Assessment

KDHO had conducted 3 annual CASPER surveys before the pandemic. In April 2020, with very few cases but severe economic impacts due to loss of tourism, KDHO conducted a fourth annual CASPER. ¹¹ Survey questions assessed economic and mental health impacts of the pandemic and related restrictions. Methodology was adapted to enable phone-only participation, for residents who preferred not to interact with door-to-door surveyors. Surveyors, all with prior CASPER experience, included KDHO staff, Kauai Medical Reserve Corps (MRC), and American Red Cross volunteers. The findings were used by the IMT to direct limited county, state, and federal resources. A fifth CASPER in summer 2022 reassessed pandemic impacts and assessed community perception of the COVID-19 response. ¹² Results of that assessment are included in each response section of this article.

Food Distribution

The 2020 CASPER survey confirmed the economic impacts of the pandemic, with more than half of households reporting job loss. Many residents were newly food insecure. The Operations Section of the IMT worked with local food banks, farmers, fisheries, and meat producers (all of whom had excess food that would typically have gone to feed more than 25,000 tourists on island each day) to distribute free food boxes islandwide. From May to December 2020, this program distributed over 12,000 food boxes to Kauai families. The community health worker (CHW) team did community outreach with a “no shame” message to reach those in need who were reluctant to come forward. This messaging was amplified by community partners and county public messaging. Low case counts, as a result of the coordinated COVID-19 response, enabled KDHO to support this response to a secondary impact of the pandemic.

Contributing Factors: Experience Responding Together

Prior response experience and preexisting relationships created a strong foundation for these challenging protective measures. Partners participate in joint emergency preparedness exercises. KDHO management staff uses the Incident Command System (ICS) with partners in the county's EOC in response to real-world events. During a record-breaking 2018 flood and landslide event, ¹³ KDHO contributed to the response by facilitating deployment of a state Disaster Medical Assistance Team to provide urgent care, pharmacy, and behavioral health services to the isolated community, using the ICS emergency response framework. Before the pandemic, KDHO staff had not held incident command or operations chief positions in the county EOC, but they had served in these roles at the departmental operations level. Although unified command shared by the county and KDHO was novel, prior participation in EOC activations and exercises, shared familiarity with ICS, and preestablished relationships with county leaders made these assignments straightforward in this health emergency. Coming together to respond to the pandemic was a novel type of disaster, but on familiar ground with trusted partners.

July 2022 CASPER Community Rating

On a scale of 1 (“very poor”) to 5 (“very good”), the weighted mean rating of the county's COVID-19 response in the area of policy and regulations was 4.15. ¹²

Kauai Residents

The first cases on Kauai, in mid-March 2020, were 2 visitors. The IMT identified, and the county requisitioned, an unoccupied county facility (intended as an adolescent treatment center) as an available, appropriate, and financially feasible isolation site. Within 12 hours of the cases being identified, this facility was converted to a dormitory-style isolation facility (with double rooms, shared restrooms and kitchenette, outdoor access, meal delivery, and onsite security) and emergency medical services transferred the visitors to the facility. KDHO staff conducted check-in and site orientation; performed their first case investigations, contact tracing, and contact notifications; implemented twice daily monitoring calls to assess wellbeing; and arranged for hot meal delivery 3 times per day. The Kauai Visitors Bureau facilitated adjustment of travel plans.

Although initially established to house Kauai's first visitor cases, the requisitioned county facility went on to house predominantly residents unable to isolate at home throughout the first 2 years of the pandemic. It was operated by KDHO staff leading the isolation and quarantine unit of the county's IMT structure. Security for the facility was arranged through an existing state contract. The local hospital provided prepared meals for pickup 3 times per day. Meal numbers and dietary specifications were provided daily to the hospital kitchen by KDHO staff. KDHO used federal COVID-19 funds to cover the cost of utilities, meals, security, and (after initial county support) grounds and facility maintenance.

Salient decisions included using the facility only for isolation of cases (not for quarantine of close contacts), prioritizing use of the facility for residents rather than visitors, and establishing baseline conduct expectations for occupants. Challenges encountered included individuals who left the facility without informing KDHO, unauthorized visitors to the facility, altercations between occupants at the facility, drug and alcohol use, and the need to transport occupants to the hospital for urgent healthcare. These events were infrequent, and each served as an opportunity to enhance services and plan for the unexpected.

Quarantine spaces for Kauai residents who were identified as close contacts, and unable to quarantine at home, were managed through agreements with local visitor accommodations, funded by KDHO. Identification of quarantine facilities and all payments were managed by KDHO, as county IMT operations co-chief.

KDHO staff, MRC volunteers, and American Red Cross volunteers provided wraparound services to residents in isolation or quarantine, whether at home or elsewhere. These included, as needed, groceries, meals, access to healthcare, prescription medications, phones, and daily monitoring.

Kauai Visitors

Managing the isolation and quarantine of visitors identified as cases or close contacts was identified as a potential diversion from responding to the needs of Kauai residents, in addition to being potentially prohibitively costly. Yet with the majority of cases being travel-related, including visitors, isolation and quarantine for this population were essential to disease containment. Hawaii's Safe Travels program, implemented on August 1, 2020, ¹⁴ required that visitors be allowed to isolate or quarantine in visitor accommodations, at their personal expense. In collaboration with the Kauai Visitors Bureau, visitors were supported in finding available rooms and changing travel itineraries. KDHO provided daily monitoring and assisted with access to healthcare services as needed, while food and necessities were primarily accessed through retail channels.

Enforcement

At the direction of the mayor, the Kauai Police Department supported enforcement of KDHO-directed isolation and quarantine. The Kauai Police Department supported KDHO staff in conducting wellness checks on COVID-19 cases who failed to respond to monitoring calls. They accompanied KDHO staff when serving formal isolation or quarantine orders. When KDHO received information that isolation or quarantine was being broken (for example, from social media posts), the Kauai Police Department reached out by phone or in person to reinforce the need to isolate and quarantine and to inform cases of potential penalties for failing to comply.

Contributing Factors: Prior Trusting Relationships

As the public health presence in the county, KDHO is consulted regularly on matters such as ocean water cleanliness, hazardous materials, wastewater, vector control, food safety, and the built environment. These consultations intersect with the visitor industry with, for example, legionella investigations, mosquito control, Zika and dengue viruses, recreational use of ocean water, and foodborne illnesses. KDHO prioritizes prompt and collaborative consultation responses. This history created trusting relationships among the partners, facilitating the rapid and enduring dedication of resources. The county's commitment of law enforcement resources to enforce KDHO orders exemplifies coordinated action built on trusted partnerships. Similarly, substantive collaboration with the visitor industry was only possible because of close working relationships with the Kauai Visitors Bureau.

July 2022 CASPER Community Rating

On a scale of 1 (“very poor”) to 5 (“very good”), the weighted mean rating of the county's COVID-19 response in the area of health-directed isolation and quarantine was 4.09. ¹²

Niihau/Kalaheo Outbreaks

KDHO has a strong Chronic Disease Prevention/Health Promotion team including a health educator and 3 CHWs who routinely provide health education, outreach, and linkage to services for the diverse communities of Kauai County. This team is multilingual, multicultural, and has well-established relationships throughout Kauai County, including the isolated Niihau community in which Hawaiian is the primary language. Their presence as COVID-19 outreach workers was an extension of their usual work, and as such was well received. Their work was especially critical to successful responses to 2 outbreaks, as follows.

The majority of early cases on Kauai were associated with travel. The first cluster involving community spread occurred in June 2020, in a Native Hawaiian/Pacific Islander community known to experience higher infection, hospitalization, and death rates from COVID-19. The CHW team's existing relationships, language skills, and community trust enabled them to reach out promptly with accurate guidance and information, and to coordinate response efforts. KDHO leadership and CHWs met, masked and in-person, with community leaders. The community leaders were initially reluctant to engage with KDHO and fearful of their community being stigmatized. As a result of that meeting, and after careful assurance of confidentiality, a mobile testing event took place for at-risk community members. More than 80 people were tested, without garnering public attention. The specific community was not publicly identified in any way (eg, by language, ethnicity, geographic location). Home isolation and quarantine were supported with robust wraparound services, and those who were unable to isolate or quarantine at home were accommodated in isolation and quarantine facilities. Home visits were made by CHWs, public health nurses, volunteers, and KDHO staff including the district health officer, to ensure that questions were answered, and directions were understood and followed. A KDHO native speaker of the community's primary language participated in these visits. This and subsequent outbreaks in the same community were successfully contained and proportionate vaccine uptake in these communities on Kauai exceeded statewide levels.

The private island of Niihau is a closed community committed to the preservation of Hawaiian language and culture. After cases were detected on Niihau and upon request of the private landowner, a small KDHO team made several visits to Niihau to provide island-wide testing, follow-up assessment of positive cases, vaccinations, and education and information. After several rounds of testing and appropriate isolation and quarantine of residents, the outbreak was brought under control and vaccination rates were improved, likely preventing further morbidity and mortality in this vulnerable isolated community. These efforts were made possible by longstanding relationships between KDHO public health nursing, CHW staff—including a team member born and raised on Niihau who has worked for KDHO for over 25 years—the mayor's office, and the Niihau community.

Training Investigators and Tracers

Case investigation and contact tracing were accomplished by KDHO staff from across a broad swath of programs. Before any substantial increase in cases on Kauai, all KDHO staff who had clinical, case management, or customer service experience were strongly encouraged to participate in online training for case investigation and contact tracing; approximately 60 did so. When their services were needed, they were prepared. In fact, these trained staff proved to be a statewide resource and supported case investigations and contact tracing in other counties with higher case rates than Kauai. MRC volunteers, Hawaii National Guard, county staff, and eventually temporary employees further supported these efforts. KDHO continues to reach out by phone to every reported COVID-19 case.

Contributing Factors: Familiarity with Disease Containment Measures

Recurring KDHO division-wide initiatives bring together staff from all programs (eg, family health services, environmental health, behavioral health, and laboratory) to work toward shared goals outside of their programmatic roles. KDHO was able to create a robust investigator/tracer team because of staff experience working together outside of their program areas and with volunteers and partner agencies, and because of their familiarity with disease containment concepts from prior training and emergency preparedness exercises.

KDHO's Public Health Preparedness team offers monthly lunchtime disaster movie showings (eg, commercial movies such as “Dante's Peak” and “Outbreak,” and documentaries such as “When the Levees Broke”). Movies are accompanied by popcorn and are interrupted for discussion of public health disaster response roles. These voluntary events are popular, engaging, and establish a baseline familiarity with case investigations and contact tracing even among staff outside of disease control programs.

July 2022 CASPER Community Rating

On a scale of 1 (“very poor”) to 5 (“very good”), the weighted mean rating of the county's COVID-19 response in the area of case investigation and contact tracing was 3.85. This was the area with the highest “don't know” response, related to respondents who had no firsthand experience with these functions. ¹²

Free Community Testing

The IMT identified limited testing access as a substantial challenge early in the pandemic. Although federal, state, and private efforts were underway to improve access to testing, the decision was made to pursue a local solution. The county made its centrally located convention hall available as a community testing center. County general funds were used to purchase rapid polymerase chain reaction (PCR) tests, later supplemented by KDHO purchases using federal funds. KDHO's branch of the state laboratory provided training and quality assurance, and the HDOH state laboratory allowed the laboratory to function under its Clinical Laboratory Improvement Amendments license. The testing center was staffed by reassigned KDHO and county employees, short-term county employees, Hawaii National Guard, and temporary workers funded by KDHO.

Opened in October 2020, the site offers free PCR testing 5 days per week, 7.5 hours per day, with same-day results in less than 4 hours. This has proven to be one of Kauai's biggest successes. Free testing is available to residents and visitors as needed—including for work or travel—with prompt results. Rapid turnaround time expedited case investigations and contact tracing, enabling prompt disease containment. During Delta and Omicron, Kauai generally performed 20% to 40% more testing, on a population basis, than the rest of the state.

With the advent of over-the-counter tests, county staff has conducted 30 events to distribute test kits at neighborhood centers island-wide, distributing approximately 45,000 HDOH-purchased tests.

Mobile Testing

A generous benefactor donated to the county 3 vans equipped for field health services. Through collaboration with KDHO, 1 van provided mobile testing island-wide, 5 days per week, in outlying neighborhoods. This further enhanced testing access, providing free PCR testing at neighborhood centers.

Community Outreach Testing

Kauai has 1 Federally Qualified Health Center with 2 locations. Their COVID-19 team prioritized community outreach to the houseless communities on Kauai, including sending teams to provide testing and distribute over-the-counter test kits at locations around the island. KDHO's CHW team supported these efforts through community outreach in advance and onsite language assistance as needed.

Contributing Factors: Capacity and Partnerships

Sustained large-scale testing was facilitated by internal KDHO and HDOH laboratory capabilities and strong partnerships with the county, the private sector benefactor, and the Federally Qualified Health Center. Each partner's willingness to contribute what they could to make testing widely available enabled implementation of activities that could not have been accomplished by any single partner, even with limitless funds. Coming together to pool resources made this valuable resource a reality. Importantly, partners each accepted some risk in doing so. Decisions were often uncomfortable, but all partners ultimately agreed the benefits of providing this service outweighed the risks.

July 2022 CASPER Community Rating

On a scale of 1 (“very poor”) to 5 (“very good”), the weighted mean rating of the county's COVID-19 response in the area of testing availability was 4.45. ¹²

Mass Vaccination Site

Vaccination responsibility was shared by KDHO, hospital partners, and the county. Hospitals took the lead on vaccinating healthcare workers and seniors. KDHO ran a vaccine point of dispensing (POD) using KDHO staff and MRC volunteers, focused on employment-based eligibility. The county provided the facility, site security, crowd control, and support services. The county's Office of Economic Development assisted with notifying employers in various job sectors as their employees became eligible for vaccination and provided contact information for appointment scheduling directly to KDHO. Onsite KDHO staff assisted residents for whom language and/or technology was a barrier to preregistration. Vaccinations were offered 4 days per week, 4 hours per day, with as many as 16 vaccination stations serving up to 800 residents per day. From December 21, 2020, to May 27, 2021, over 32,000 doses were administered at this site. During this period, over 74,400 vaccine ⁵ doses were administered in Kauai County from all sources. Thus, the vaccine POD accounted for nearly half of the countywide doses.

Kauai was able to move through vaccine priority groups expeditiously, and open broadly to each category as it became eligible. Special clinic hours were held to accommodate educators outside of instructional hours. Visitor industry workers were prioritized due to the importance of their work for the local economy and their heightened exposure risk.

Mobile Vaccinations

Through collaborations with hospitals and KDHO, the county was able to use 2 of the donated vans previously described to bring vaccination efforts into the community, improving access. One van was used for scheduled vaccinations on request, at homes, businesses, and community settings. The first vaccination delivered with this van was to a resident who had lost an unvaccinated relative to COVID-19. The second van was operated by hospital partners and provided vaccines at scheduled locations island-wide.

Community Outreach Vaccinations

The community outreach by Kauai's Federally Qualified Health Center to the houseless communities on Kauai included providing onsite vaccinations at the dedicated houseless camps at the county campgrounds as well as other houseless encampments around the island. KDHO's CHW team supported these efforts through community outreach in advance and onsite language assistance for these efforts as well as for education and testing outreach.

Contributing Factors: ICS and POD Experience; Healthcare Partnerships

KDHO leadership prioritized emergency response preparedness before the COVID-19 pandemic. Staff regularly participate in Stop Flu at School ¹⁵ annual vaccination clinics, periodic military Innovative Readiness Trainings, ¹⁶ and annual CASPER surveys. Staff have assigned roles outside of their routine responsibilities, practice using ICS as an organizational tool, experience just-in-time training, participate in after-action hotwashes, problem-solve in the field, and become better acquainted with colleagues. In addition, they work alongside MRC; American Red Cross; and military, education, and healthcare partners. These experiences built skills that jump-started POD operations and facilitated adjusting to changing levels of demand. ICS is a familiar and valued tool for KDHO staff, and they were able to use it effectively in the pandemic response.

Healthcare partners played an essential role in vaccinations—as providers of vaccination and as priority recipients of vaccinations. KDHO routinely works with healthcare partners on issues such as disease reporting, infection control, and community health needs assessments. Under the auspices of the Hospital Preparedness Program, KDHO began convening healthcare entities, ranging from dialysis centers to laboratories to clinics and hospitals, to share capacities and gaps and facilitate communications and situational awareness in future disasters. There had been 2 annual convenings of this group before the pandemic, which facilitated early communications when the pandemic hit. Well-established partnerships facilitated a coordinated response.

July 2022 CASPER Community Rating

On a scale of 1 (“very poor”) to 5 (“very good”), the weighted mean rating of the county's COVID-19 response in the area of vaccine rollout and availability was 4.44. ¹²

County Takes the Lead

The HDOH communications team is located on Oahu and has limited resources for county-level communications, and KDHO has no social media presence. In contrast, the county has an active local communications team with strong social media presence including Facebook and Instagram, as well as a county website that is updated daily. The county took the lead in COVID-19 communications, expanding their frequency to include daily COVID-19 press releases and video messages, and radio and print media. All health-related content was codeveloped by KDHO and the county communications team.

A dedicated county COVID-19 web page became a “one-stop shop” for Kauai-specific information about COVID-19. ¹⁷ This included daily case counts and fatalities, where to get tested or vaccinated, links to additional sources of information, and current policies and regulations. This information was also provided in daily video updates featuring the mayor, IMT members, and community leaders and partners. These videos are cited by residents as being particularly useful and engaging.

The mayor posted daily #stayhomekauai social media videos ¹⁸ on Instagram, Facebook, and occasionally on TikTok. Multilingual public service announcements were recorded for local radio by KDHO staff. The mayor and the district health officer appeared on Facebook Live events hosted by local political commentators.

Travelers

The county communications team, in consultation with KDHO, created educational videos providing essential COVID-19 information. These were played in airport arrival terminals and provided critical information to returning residents and arriving visitors, including travel-related quarantine and testing requirements, how to get tested, and where to access additional resources.

Community-Based Communications

KDHO CHWs, in their on-the-ground community outreach work, acted as extensions of these public communications. They assisted residents in using these resources, translated the resources both linguistically and culturally, and answered questions and concerns in person. They were the multilingual voices on local radio.

Contributing Factors: Prioritization

Both the county and KDHO made public communications a top priority, and their communications were one and the same. The community saw the mayor, district health officer, and community leaders stand together, side-by-side, in accord at every juncture as the pandemic unfolded. The strong foundation of mutual trust among leaders made this close collaboration not only possible, but natural. That translated into consistent messaging that the community saw as credible.

July 2022 CASPER Community Rating

On a scale of 1 (“very poor”) to 5 (“very good”), the weighted mean rating of the county's COVID-19 response in the area of public information was 4.42. ¹²