Pre-arrival screening:Seventy-two hours prior to the first day of a camp session, the medical team assessed the level of SARS-CoV-2 transmission within the 11 counties surrounding camp. An a priori definition of risk included low risk, intermediate risk, and high risk (Figure 1).

Figure 1Pre-arrival risk stratification of SARS-CoV-2 community spread

If community risk was low, prearrival mitigation strategies and in session mitigation strategies were implemented as described below. If community risk was intermediate, the same mitigation steps as low risk were implemented in addition to performing rapid SARS-CoV-2 NAAT upon arrival to camp for all individuals coming from counties with non-low–risk community infectivity. If community risk was high, the camp did not open for that session.

Mitigation steps:

Prearrival mitigation steps included a prearrival screening phone call and prearrival SARS-CoV-2 testing. Screening phone calls were performed by the medical staff calling the camper’s family 2 wk prior to arrival to evaluate travel/exposure history. The medical staff also informed the family that the household should quarantine until arrival to camp. Prearrival testing involved all campers providing documentation of a negative SARS-CoV-2 PCR from within 72 h prior to arrival on site.

In-session mitigation steps:

Staff vaccination mandate: All staff and volunteers were required to be fully vaccinated against SARS-CoV-2 2 wk prior to arrival on site.

Daily symptom screening: Every morning prior to leaving their cabin, all staff members and campers underwent a standardized symptoms screen by medical staff (Pinpoint SARS-CoV-2 screening, Wellcheck. Monkton, MD). If an individual reported any symptom, they were evaluated by the camp physician.

Cohorting: On site cohorts were made up of 10 campers and 5-7 staff members.

Universal masking: Masks were worn by all campers/staff unless the only people present were within the on-site cohort, they were eating/drinking, participating in an aquatic activity, or they were sleeping.

Intentional staffing pattern: Activity areas that required specific training/certifications had dedicated staff assigned to that area and were counted within an on-site cohort. This allowed for small cohorts without a lot of “cross contamination” within a program area by program staff.

Intentional common space utilization to allow for social distancing: Each on-site cohort had a designated indoor and outdoor dining area as to physically distance every cabin from one another while all masks were down during mealtime.

Specific person under investigation protocols: Any potentially infectious complaint was evaluated in an infirmary physically separate from the noninfectious infirmary. Any infectious complaint had a rapid SARS-CoV-2 NAAT performed on site. If negative, they could return to camp activities per standard medical policies. If positive, the whole cabin cohort was sent home.