The infection rate for COVID-19 in Hawaii has been trending up since Christmas.

On Dec. 25, Hawaii was still listed in the medium range for infection spread. But Hawaii’s rising infection rate now has it listed as the fourth-worst state for spread after Maine, Iowa and New York, according to rt.live, a website developed by Instagram’s founders that tracks how fast COVID is spreading in each state.

Hawaii had an infection rate of 1.03 on Christmas Day. However, by Saturday, Hawaii had a 1.1 infection rate, which means that each person in Hawaii with COVID is on average infecting 1.1 other people.

Infection rates are used to determine how likely the virus is to spread. An infection rate below 1.0 means the virus will stop spreading, but an infection rate above 1.0 means the virus is growing, and is a predictor of higher daily cases in the future.

Hawaii’s per capita number of new cases daily is still the lowest in the nation at 8.9 per 100,000 population, according to the Centers for Disease Control on Sunday. The state with the most was California at 98.8.

Hawaii health officials Sunday reported 149 new coronavirus infections, including 88 on Oahu, 30 on Maui, two each on the Big Island and Kauai, and 27 state residents diagnosed outside of Hawaii. The statistics released Sunday reflect the new infection cases reported to the state Health Department on Friday.

Hawaii is veering into increased risk of spread at a time when the U.S. is experiencing a third wave of COVID-19 cases. The U.S. coronavirus death toll rose above 350,000 Sunday, with total coronavirus cases across the nation now topping 20 million.

Lt. Gov. Josh Green, who is in charge of Hawaii’s COVID testing and vaccination program, said in a text, “We’ve had a modest increase in cases over Christmas holiday but it’s been less by far than virtually any other part of the country.”

“If we’re disciplined in the coming weeks, now that New Years has passed, meaning we minimize gatherings and wear masks, we should settle back into the double digits,” Green said.

Green said a drop in COVID caseloads would allow Hawaii to focus on the vaccination effort, “which is going to really rev up in about 2 weeks.”

“We are expecting significantly more doses of the Pfizer and Moderna vaccine mid-month (aiming for 150,000 doses a month) and will be launching large vaccination pods statewide then, with ways for our Kupuna to easily sign up and get their shots at mega-centers led by our healthcare partners” and the state Department of Health, Green said.

In the meantime, Green said, one of his largest concerns is that the recent rise in infections has led to three weeks of increased hospitalizations. He said “hospital numbers (patients with COVID) have moved from around 60 to 90 on average statewide.”

According to the latest information from the Health Department, 101 patients with the virus were in Hawaii hospitals as of Wednesday, with 11 in intensive care units and nine on ventilators.

“We need to reverse this trend right away,” Green said. “We have been seeing about 7.5% of all cases require hospitalization so this pattern has held. If we lower our daily case count back to under 100, our hospital numbers will drop quickly. I’m optimistic we can control the virus in the first quarter of this year if we make smart decisions as people.”

COVID spread has kept Oahu, the island where the bulk of Hawaii’s COVID cases are occurring, stuck at Tier 2 of its four-tier economic recovery plan, since Oct. 22. To gauge whether Honolulu will move to a different tier, the city takes a “weekly assessment” of two key COVID-19 numbers each Wednesday. To move to Tier 3 from Tier 2, the seven- day average of new cases must be below 50 on two consecutive Wednesdays. Also, the seven-day average positivity rate must be below 2.5% on those two Wednesdays.

Sunday’s seven-day average case count for Oahu was 97, and the positivity rate was 4.3%, according to Mayor Rick Blangiardi, who was serving his first full day in office Sunday.

State health officials didn’t report any new hospitalizations or deaths Sunday.

The statewide death toll remains at 289. The state’s official coronavirus-related death toll includes 224 fatalities on Oahu, 45 on Hawaii island, 17 on Maui, one on Kauai and two Hawaii residents who died on the mainland. The Hawaii County Civil Defense Agency said Friday that the Big Island’s COVID-19 death toll remained at 51, but state officials have not verified the novel coronavirus as a factor in six of those fatalities.