Hawaii hospitals are predicting a third and potentially more devastating wave of COVID-19 on the horizon as flu season gets underway, schools and tourism reopen and more people gather during the holidays.

The worst local surge in coronavirus infections is anticipated in the final months of the year, with as many as 400 to 450 COVID-19 patients potentially being admitted into the hospital each month in December and January, according to the Queen’s Health Systems, which has a disease modeling team that has been studying waves of past pandemics to forecast future surges. By comparison, Queen’s treated 341 COVID-19 patients during the peak of the pandemic in August.

“The thing I’m most worried about right now in the fall and through December is we have major holidays: Halloween, Thanksgiving, Christmas. All of those times when we have great aloha and usually gather with our ohana and friends. You have many more opportunities to transmit a disease when you’re asymptomatic and don’t know you have it,” said Jill Hoggard Green, president and CEO of the Queen’s Health Systems.

In addition, health experts forewarn that as schools reopen, there will be more outbreaks and while travelers are required to be tested to avoid the state’ 14-day quarantine starting Oct. 15 “that is not going to catch everyone,” said Hilton Raethel, president and CEO of the Healthcare Association of Hawaii, representing Hawaii’s hospitals and nursing homes.

“Between the prevalence already out there in the community and the public schools opening up and trans-Pacific travel opening up in combination with the flu season, we absolutely anticipate there will be another surge of COVID-19 in Hawaii,” he said. “We’re preparing for the worst, but obviously, we hope it’s not going to happen.”

A third wave is particularly concerning because Hawaii’s coronavirus cases have plateaued at about 100 cases a day, a significantly higher baseline than in the earlier months of the pandemic.

“Because we’re already starting at about 100 cases a day, the potential for the outbreak to get worse is there unless we do what we need to do,” Raethel added. “We understand that people want to get together and celebrate Thanksgiving and the holidays, but the reality is while we’re dealing with a pandemic, until we have a cure, we have to do all we can to minimize spread of the disease.”

With flu in the mix, there also will be two potentially deadly respiratory viruses circulating in the community, which is why health officials are urging people to get a flu shot to minimize the risk of weakening the immune system.

“We’ve got to keep the messaging up so that people understand they cannot let their guard down. There is a very real potential that there will be an increased infection rate and increased death rate above and beyond what we just recently experienced,” Raethel said. “While we are better prepared in many ways and we may be able to take care of more patients … that’s not something we want to do. We would much prefer that people don’t die because of COVID-19.”

To that end, the state is ramping up testing and contact tracing and bringing in 240 specialty nurses, critical care clinicians and respiratory therapists from the mainland to boost hospital staffing ahead of any year-end outbreaks. That will allow smaller hospitals to open up more beds and increase capacity in the winter months.

The hospital association is also stockpiling the antiviral medication Remdesivir, which was approved by the U.S. Food and Drug Administration for the treatment of severe COVID-19 infections under an emergency-use authorization.

Travel nurses and emergency personnel will be deployed at eight Oahu hospitals, Maui Memorial Medical Center and Hilo Medical Center. The Healthcare Association of Hawaii said it is also working on contracting 60 other nursing staff to be deployed as strike teams to handle COVID-19 clusters that emerge in long-term care facilities on Oahu, Maui and Hawaii island.

To avert a health care crisis, hospitals are urging people to continue wearing masks and practicing good hygiene, as well as find alternatives to gathering during the holidays.

“If we can do that we have a very good chance of not having surges the way we predict them,” Green said, adding that Queen’s has rapidly built a 24-bed infectious disease unit with negative pressure isolation rooms ahead of the expected increase. “Those are very important things to make sure we not only survive, but we thrive through this pandemic and we are safe and supporting each other.”

Another surge could mean returning to lockdown restrictions in the islands — already grappling with thousands of jobless residents and worries about additional mass layoffs — which would be the only way to control the spread of disease without a vaccine, said Dr. Melinda Ashton, executive vice president and chief quality officer at Hawaii Pacific Health — parent company of Kapiolani Medical Center for Women & Children, Pali Momi Medical Center, Straub Medical Center and Wilcox Health on Kauai.

Oahu’s seven-day average case count must stay below 100 and its positivity rate must be below 5% for 14 consecutive days to move to the next level of economic opening. Honolulu’s most recent seven-day average case count is at 96.6.

“Until we have an effective treatment or effective vaccine … the only other sort of lever we have to pull is increasing restrictions. The economy just can’t function if we don’t have the pandemic under control,” Ashton said. “We are at a place where we could exponentially rise in case numbers again very quickly.”

Mitigating the risk of infection is in each individual’s hands and “how well we as a community continue to do all the right things,” she said, adding that hospitals are seeing an increase in flu vaccinations compared to year’s past.

With the opening of travel, “we do expect to see more COVID-19 for sure,” Ashton said. “We’re all hopeful that travelers will want to come and we know our economy needs it — that’s a necessary evil.”

“Hopefully, this most recent surge in cases was concerning to people and they sort of reengaged in social distancing and mask wearing. On the other hand, we know people are pretty tired of all the restrictions,” she said.

Health officials reported three additional coronavirus deaths and 108 new infections statewide — representing 5.9% of the 1,817 new tests tallied — bringing the total since the start of the pandemic to 139 deaths and 12,515 cases. The Oahu fatalities included two men between the ages of 60 and 79, and a woman in the 80- to 89-year-old age group — all with underlying medical conditions.

There are 2,036 active infections statewide, and a total of 10,340 patients now considered recovered, or 82.6% of those infected. The U.S. death toll has topped 207,000.

“Until we have enough people in the community vaccinated, we have to keep wearing masks, practice social distancing and avoid large gatherings,” Raethel said. “We understand that it is an incredible challenge, but the reality is COVID-19 doesn’t care who you are. It can impact kids, young people, adults. There are some devastating consequences from catching COVID-19. Unless we are vigilant we will continue to experience material outbreaks and the more widespread it is in the community, the more it’s going to impact our nursing homes and our hospitals.”