To describe epidemiologic and genomic characteristics of a severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) outbreak in a large skilled-nursing facility (SNF), and the strategies that controlled transmission.

This cohort study was conducted during March 22–May 4, 2020, among all staff and residents at a 780-bed SNF in San Francisco, California.

Contact tracing and symptom screening guided targeted testing of staff and residents; respiratory specimens were also collected through serial point prevalence surveys (PPSs) in units with confirmed cases. Cases were confirmed by real-time reverse transcription–polymerase chain reaction testing for SARS-CoV-2, and whole-genome sequencing (WGS) was used to characterize viral isolate lineages and relatedness. Infection prevention and control (IPC) interventions included restricting from work any staff who had close contact with a confirmed case; restricting movement between units; implementing surgical face masking facility-wide; and the use of recommended PPE (ie, isolation gown, gloves, N95 respirator and eye protection) for clinical interactions in units with confirmed cases.

Of 725 staff and residents tested through targeted testing and serial PPSs, 21 (3%) were SARS-CoV-2 positive: 16 (76%) staff and 5 (24%) residents. Fifteen cases (71%) were linked to a single unit. Targeted testing identified 17 cases (81%), and PPSs identified 4 cases (19%). Most cases (71%) were identified before IPC interventions could be implemented. WGS was performed on SARS-CoV-2 isolates from 4 staff and 4 residents: 5 were of Santa Clara County lineage and the 3 others were distinct lineages.

Early implementation of targeted testing, serial PPSs, and multimodal IPC interventions limited SARS-CoV-2 transmission within the SNF.

Operational stress describes individual behavior in response to the occupational demands and tempo of a mission. The stress response of military personnel involved in combat and peace-keeping missions has been well-described. The spectrum of effect on medical professionals and support staff providing humanitarian assistance, however, is less well delineated. Research to date concentrates mainly on shore-based humanitarian missions.

The goal of the current study was to document the pattern of operational stress, describe factors responsible for it, and the extent to which these factors impact job performance in military and civilian participants of Continuing Promise 2011 (CP11), a ship-based humanitarian medical mission.

This was a retrospective study of Disease Non-Battle Injury (DNBI) data from the medical sick-call clinic and from weekly self-report questionnaires for approximately 900 US military and civilian mission participants aboard the USNS COMFORT (T-AH 20). The incidence rates and job performance impact of reported Operational Stress/Mental Health (OS/MH) issues and predictors (age, rank, occupation, service branch) of OS/MH issues (depression, anxiety) were analyzed over a 22-week deployment period.

Incidence rates of OS/MH complaints from the sick-call clinic were 3.7% (4.5/1,000 persons) and 12.0% (53/1,000 persons) from the self-report questionnaire. The rate of operational stress increased as the mission progressed and fluctuated during the mission according to ship movement. Approximately 57% of the responders reported no impact on job performance. Younger individuals (enlisted ranks E4-6, officer ranks O1-3), especially Air Force service members, those who had spent only one day off ship, and those who were members of specific directorates, reported the highest rates of operational stress.

The overall incidence of OS/MH complaints was low in participants of CP11 but was under-estimated by clinic-based reporting. The OS/MH complaints increased as the mission progressed, were more prevalent in certain groups, and appeared to be related to ship’s movement. These findings document the pattern of operational stress in a ship-based medical humanitarian mission and confirm unique ship-based stressors. This information may be used by planners of similar missions to develop mitigation strategies for known stressors and by preventive medicine, behavioral health specialists, and mission leaders to develop sensitive surveillance tools to better detect and manage operational stress while on mission.

ScoutenWT, MehalickML, YoderE, McCoyA, BrannockT, RiddleMS. The Epidemiology of Operation Stress during Continuing Promise 2011: A Humanitarian Response and Disaster Relief Mission aboard a US Navy Hospital Ship. Prehosp Disaster Med. 2017;32(4):393–402.