Abstract
To the Editor:
We read with great interest the recent article “Evaluation of Safety Measures at a Medical Summer Camp During the SARS-CoV-2 Pandemic” describing the authors’ experience mitigating the potential spread of SARS-CoV-2 at a summer camp for medically complex children—in particular, their use of community case rates to direct prearrival testing and the use of symptom-driven testing during the camp itself. 1 We would like to share our own experience operating a wilderness medicine student elective during the COVID-19 pandemic using a symptom-driven screening protocol.
From 2020 through 2022, 42 individuals (medical students, emergency medicine residents, and attendings) participated in a wilderness medicine elective consisting of a backpacking trip that lasted 7 d. A symptom-driven protocol was developed to screen for potential cases of SARS-CoV-2 infection. When the protocol was created, there was no available vaccine, polymerase chain reaction (PCR) testing was difficult to perform, and the impact of false-positive results in low-prevalence settings was unclear.2,3 Additionally, as the elective was conducted entirely in the field, proper storage of newly available rapid antigen testing kits was not possible. 4 With those statements in mind and our population young and healthy, mandatory prearrival testing or testing during the course was believed to be unnecessary. Instead, we utilized recommendations from the Centers for Disease Control, the American Camp Association, and our own institutional Infection Prevention and Control group to create a protocol that relied purely on symptom-driven triggering of testing or intervention.5,6 The data collection was granted an exemption by the Institutional Review Board at Icahn School of Medicine at Mount Sinai.
The protocol itself was composed of 7 facets, many of which overlapped with those utilized by the authors: 1) precourse and daily symptom screening; 2) single-person or “social bubble” tenting; 3) masking in enclosed areas; 4) hand hygiene; 5) mandatory vaccination (once available); 6) isolation or departure of symptomatic participants in-session; and 7) testing of symptomatic participants. The prearrival screening included the 10 d immediately preceding the elective. If an individual screened in, they were required to provide a negative PCR test result prior to participation. Further screening was conducted on a daily basis during the course; in the instance of a positive screen, mildly symptomatic participants would be instructed to wear a mask, socially distanced for the remainder of the course, and offered early departure if logistically feasible. If moderate or severe symptoms presented, they were evacuated. We also incorporated 14 d of postcourse symptom monitoring similar to the authors.
When this protocol was in effect, there were 0 suspected or confirmed cases of SARS-CoV-2 infection; no participants screened positive during prearrival, in-session, or postcourse monitoring. Of note, the case rates per 100,000 individuals in our area during the 2 wk prior to the elective were 2, 16, and 18 during 2020, 2021, and 2022, respectively. 7 This correlates with low and intermediate risk based on the a priori limits used by the authors. However, while their protocol required mandatory prearrival testing in the setting of intermediate risk rates (10–25 cases per 100,000), ours did not. Instead, we used a binary “go/no-go” trigger of local high-prevalence rates prompting cancellation of the entire course.
Although the case rate among our participants was 0, it is difficult to draw any conclusions as to the impact of the protocol. The low rate of transmission may have been due to the small sample size, the SARS-CoV-2 prevalence rates at the time, high vaccination rates, asymptomatic infections, or other confounding factors. Upon reflection, in future iterations of the protocol, we would likely perform arrival or prearrival rapid testing in situations where the local prevalence rate is intermediate, similar to the authors. We believe a purely symptom-driven approach to screening may serve a purpose in outdoor activities, attempting to balance cost, safety, and convenience. Such a protocol can also be applied in the absence of a pandemic and for illnesses other than SARS-CoV-2 infection. For example, during the traditional influenza season, it might serve to limit spread among an outdoor group and work to prevent illness and the associated healthcare and societal costs. Ultimately, we applaud the authors for describing a protocol incorporating community rates and symptom screening to mitigate SARS-CoV-2 spread and acknowledging the careful balance required to do so safely in a medically complex participant population.