COVID-19 and British Columbia’s volunteer search and rescue workers: risk recognition and risk mitigation

Background: Early during COVID-19, British Columbia coordinated collaboration between academic researchers, public healthcare systems, and private sector partners to focus research resources on knowledge gaps in a timely manner, avoid duplication, and identify overlooked aspects. At a collaboration symposium, it became evident that BC’s volunteer search & rescue (SAR) cadre was overlooked. Objective: Our exploratory project studied volunteer SAR’s operational readiness; use and perceived value of information sources; consistency in infection prevention measures among volunteer stations, and with their professional counterparts for comparable first aid medical interventions throughout the pandemic. Methods: We partnered with the 2 organizations that govern BC’s volunteer SAR stations. Local station leaders completed a short confidential survey. Guidance documents issued by associations governing voluntary and professional first responders were compared. Results: Survey responses were received from 33 of 109 local stations, spanning all regions of BC. Most remained operationally ready throughout the entire pandemic (12.1% had to stand down at times). Except for 21% lacking eye protection, all had personal protective equipment commensurate with that of healthcare professionals; however, few used this PPE in a manner consistent with professional counterparts. Usage and perceived usefulness of various information sources differed. There was no communication link between the province’s infection control experts and 2 volunteer SAR organizations. Conclusions: Search & rescue capability was maintained despite pandemic impacts. Results reveal strengths and opportunities for improvement in the ways volunteers are informed and protected. Infection control experts providing advice for emergency health services professional responders should remember to include their volunteer counterparts.


Introduction
Early in the COVID-19 pandemic, British Columbia coordinated collaborative efforts between its academic researchers, public healthcare systems, and private sector partners to focus research resources on knowledge gaps in a timely manner, avoid duplication of effort, and identify any overlooked aspects.During its September 2020 free public BC COVID-19 Research and Collaboration Symposium, it became evident that no research had been initiated to understand impact on BC's volunteer search & rescue (SAR) cadre. 1 Despite being an extension of BC's emergency services, it is possible that volunteer SAR first responders did not receive timely updates and communications regarding COVID-19 infection prevention for risk recognition and mitigation during first-aid procedures commensurate to their professional counterparts for self-protection during comparable medical interventions.The implication is not that volunteer SAR members face identical frequency or magnitude of COVID-19 infection risk as healthcare professionals inside hospitals; rather, it is that there should be consistency in precautions taken during comparable risk exposure procedures.For example, resuscitating drowning victims is comparable to the aerosol-generating hospital procedure of nebulized sputum induction; administering high-flow supplemental oxygen (whether during first aid in rescue or medical care inside hospitals) has been designated as a possible aerosol-generating procedure. 2pproximately 3,500 individuals volunteer on BC's SAR crews.Volunteer marine SAR is governed by the Royal Canadian Marine Search and Rescue (RCMSAR), organized in 31 local stations around the province (https://ccga-pacific.org/about.php).Ground-based SAR is governed by the British Columbia Search and Rescue Association (BCSARA), organized in 78 local stations (https://www.bcsara.com/about/sar-in-bc/).Local station volunteers, the first link in continuity of care, often respond to prevent loss of life, rendering first aid in emergency situations in support of professional Coast Guard, paramedic, police, or firefighter first responders.Trained volunteers can often be the first on scene or the only responding unit.These ordinary citizens, from all backgrounds, ages 20s through 70s, are tasked out in teams by BC's Rescue Coordination Centre (https://www.canada.ca/en/department-national-defence/services/operations/military-operations/types/search-rescue/western-canada.html) on thousands of missions each year to locate, stabilize, and rapidly transport people in distress to higher levels of care.Stations are primarily self-funded (charitable grants & donations), government-reimbursed only for fuel-type supplies during missions.
British Columbia Search and Rescue Association and RCMSAR kept their local stations informed by periodically sending information and instructions to station leaders throughout this pandemic, and posting such documents in member-only website sections.Local stations may have supplemented this with other sources of timely information related to the evolving COVID-19 situation.The extent to which this optimized risk recognition and mitigation practices within local stations, or resulted in consistency of measures across stations, has not previously been assessed by either organization and until now wasn't addressed by BC's academic research community.Whether volunteer SAR is an overlooked sector; current evidence-informed infection control measures during aerosol-generating procedures in hospitals differ from commensurate practices among first responders; different SAR units within marine and ground-based organizations have been kept advised in different ways and whether that led to inconsistencies in practices; whether inconsistencies might leave some units at greater risk than others; and in what ways COVID-19 impacted the health and operational readiness of SAR units, are pertinent questions.

Methods
This project had 3 phases: (1) survey of local stations, (2) review of official update documents provided to them throughout the pandemic by BCSARA and RCMSAR independent of each other, and (3) comparison of advice and practices within this volunteer SAR community versus concurrent advice and practices among their professional first responder and healthcare professional counterparts.The research protocol was approved under UBC Research Ethics Board certificate H21-00757.
Our literature search failed to find any previous work of this nature, so a survey questionnaire was devised by one of the authors experienced both as a hospital epidemiologist and volunteer SAR crew member (DB).Initial drafts were reviewed by all members of the academic team for refinement, then shared with officers of our community partners (BCSARA & RCMSAR) to confirm face and content validity.End result was a combination of open-ended, interval Likert-scale, and ratio-scale questions.The form contained three questions regarding what sources of information stations found useful, one regarding what personal protective equipment (PPE) items they'd used and how acquired, and three regarding extent to which COVID-19 impacted ability to maintain operational readiness.
In March 2022, a questionnaire and cover letter requesting voluntary participation was emailed by RCMSAR to all its 31 station leaders and by BCSARA to all its 78 local station leaders across the province.A reminder prompt to respond was emailed midway through the 2-4 week request deadline period.Application of the Finite Population Correction Factor 3 to statistical power calculation set 44 for BCSARA & 23 for RCMSAR as maximum sample size, 15 & 12 as respective minimums, required to estimate true proportions within ±10% at a 95% confidence level.Surveys were completed and returned by station leaders via email to the study's academic research lead, compiled after removing personal identifying information, and descriptive summary statistics preserving confidentiality were generated using IBM SPSS version 28.0.0.0 (190).Bonferroni correction was applied for multiple comparisons. 3date documents independently issued by BCSARA, RCMSAR, and their professional counterparts (emergency health services' firefighter or police first responders and paramedics) were obtained from those organizations, compared in side-by-side reading with each other and what station leaders indicated had or had not been used locally.

Survey response rate & pattern
Survey responses were provided by 10 of the 31 RCMSAR and 23 of the 78 BCSARA local stations (overall 30.3% response rate).The province is divided into 6 regions by Emergency Management BC (see map, https://www2.gov.bc.ca/assets/gov/public-safety-and-emergencyservices/emergency-preparedness-response-recovery/embc/embc_ regional_office_map_by_regional_district.pdf).Responses were received from local stations in large urban and smaller rural locations throughout all six regions.

Survey answers
Except for eye protection (face shield or safety goggles), all had PPE protective against all routes of COVID-19 transmission initially thought possible (Tables 1-3).However, volunteers differed from professionals in mask selection criteria (Tables 4 and 5).Also, not all SAR stations have replaced latex with nitrile gloves, unlike hospitals, which started replacing latex as an allergy safety issue about 25 years ago.
Beyond BCSARA and RCMSAR, COVID-19 information was available from the Provincial Health Officer, the BC Centre for Disease Control (BCCDC), the Public Health Agency of Canada (PHAC), and elsewhere (Figure 1).Differences in distribution of rankings by BCSARA versus RCMSAR (Figure 1) are not statistically significant (p > 0.05, normal approximation to Wilcoxon rank sum test with Bonferroni and Finite Population Correction Factors applied). 3,4Reasons given for considering some more helpful than others include being issued in sufficiently timely manner, containing up-to-date information and coming from a reputable source; clarity; having content specific to SAR activities (although one commented it was not clear whether documents labelled as advisories were mandatory or simply recommendations); and ease of access ("push" modalities like emailed updates and television broadcasts favored over "pull" modalities like having to visit websites).Some commented that monitoring websites is not only time-consuming but also could be subject to individual interpretations.Headquarter mailings were, by far, the source most frequently reported by station leaders and always shared with their members.Update information from health officers was also watched less consistently but still relatively frequently.Health officer updates broadcast often (relating weekly case counts and trends, periodically announcing new precautions), while headquarter update frequency was intermittent (issued only when it was deemed necessary to announce changes in precautionary SAR practices), so it is not surprising that more respondents reported sharing all headquarters updates with their members versus sharing health officer information only if it contained important changes.Among the 33 responses, 20 provided a usefulness ranking for "other" source(s) of guidance (the other 13 left that line blank).Within those 20, 8 ranked "other" sources as highly useful (scoring as 1-3); 6 of the 8 identified use of news media, local healthcare professionals or their regional health authority, an epidemiologist, or foreign websites (CDC, WHO); the remaining 2 did not identify any "other" source as having been used.Thus, of the 6 identifying the use of specific "other" sources, 50% rated them as highly useful.At the other extreme, 9 of the 20 ranked "other" sources as least useful (scoring at 6-8), 2 indicating using information shared from other workplaces; however, 7 indicating no other source was actually used.Among all 20, the most common other sources used (listed from most to least frequent) could be classified as: Only one instance was sharing information between local stations mentioned, and there was no indication of BCSARA or RCMSAR headquarters enlisting advice from the few infectious diseases epidemiologists identified by local stations.Regarding COVID-19 impacting operational readiness, constraint of training was a common refrain.Several mentioned this delaying attainment of advanced specialization certification and making it more difficult to maintain communication, morale, proficiency, and/or recruitment.Some used virtual modalities when in-person training was prohibited; while some virtual sessions may have been recorded for future use, there was no indication of sharing archived locally produced resources outside of individual stations.Fifty-four per cent of respondents reported no loss of active members due to pandemic concerns; others reported from 2% to 25% loss due to individual concerns about personal risk, someone contracting COVID-19, or, in a few cases, refusing to divulge vaccination status or frankly expressing antivaccine and anti-masking behavior.In some, this resulted in losses among the limited number of leadership-level team members.Dedicated volunteers enabled the vast majority of local stations to remain available for all emergency taskings throughout the pandemic, although some noted having to respond with fewer than the usual size crew on SAR missions.Only 12.1% had to stand down at times, being unavailable for periods ranging from 1 day (2 stations), a couple of weeks (one station), to months (one station).
Presuming our respondents are representative of all BC's local volunteer SAR stations, these estimates can be made for percentages among all 109 local stations across the province (95% confidence interval calculated by Poisson 5 or binomial approximation, with Finite Population Correction Factor 3 applied): • Able to remain in service without interruption: 79%-97%

Comparison of BCSARA, RCMSAR, & professional first responder update documents
On 11 March 2020 BCSARA and on 12 March 2020 RCMSAR initially alerted their members.Within a few days, the 2 organizations diverged on information sources (both relying on provincial websites oriented for the general public, RCMSAR also taking Canadian Coast Guard circulars, only BCSARA citing the provincial update website dedicated to keeping emergency first responders informed).BCSARA and RCMSAR also diverged in emphasis (one quicker to prohibit large or non-essential gatherings; one quicker to encourage stockpiling essential supplies in recognition of coming supply chain disruptions; etc.).One organization seemed, early in 2020, to mandate wearing a mask when in close face-to-face contact (as in rendering first aid) as standard operating procedure while the other encouraged mask usage when social distancing cannot be maintained but initially stipulated that it remained a personal choice (later changing usage to a station-level choice until months later changing it to a headquarters-level universal requirement for all personnel).National shortages of medical grade masks prompted hospitals and ambulance services to develop instructions for safe storage and individual reuse of disposable N95 masks by their professionals; conversely, volunteer SAR members received instruction to not reuse masks.As mutant virus variants of concern arose and understanding of transmission dynamics grew, periodic infection prevention advisory updates were issued by federal and provincial officials in public health and other government agencies.Nongovernmental organizations, like BCSARA and RCMSAR, contextualized these updates in notices for their members.British Columbia Search and Rescue Association and RCMSAR's updates differ in format.British Columbia Search and Rescue Association each address 1 specific topic (e.g., mask use) or audience (e.g.incident commander); RCMSAR duplicate the previous comprehensive coverage of all topics, with section headings indicating date of an update to that individual section.Table 6 summarizes the crux of all these updates in the order they were issued.

February
Further eases restrictions on numbers and activities.

March
Changes mask use to required in 4 specific situations, otherwise reverts to a personal choice.

April
Reduces required mask use to 2 situations, otherwise a personal choice.
On 13 February 2020, the Canadian Coast Guard instructed its crew members when boarding vessels in response to medical distress to wear an N95 mask (and implies fit testing) plus place a surgical mask on the patient among airborne & contact precautions to be taken. 6On 19 March 2020, because of COVID-19 concerns, BC licensed paramedics were instructed to wear "airborne PPE" including N95 mask and face shield when performing cardiopulmonary resuscitation (CPR) and cover the patient's face with a surgical mask or viral-filter-equipped airway management device.On 22 March, they were cautioned to "use the lowest oxygen flow rate possible to achieve a SpO 2 of 90" and on 23 March 2020, their emergency call takers were instructed to "advise the public to provide hands-only CPR for adults in cardiac arrest and to cover the patient's mouth and face." 7On 1 April, professional first responders were instructed to "perform compression-only CPR and defibrillation as necessary with no oxygenation or airway management until paramedics arrive" (memo from BC Emergency Health Services Chief Medical Officer to The Fire Chiefs Association of BC, https://fcabc.ca/index.php/covid-homepage).Volunteer SAR first responders received no such advice from their organizations to change from full CPR to chest compression only (likely because those organizations assumed their contracted first-aid training providers would intercede).
Neither BCSARA nor RCMSAR volunteers were designated with official emergency first responder status by the provincial government (personal communications, BCSARA, & RCMSAR).There was no communication or requests for information between these 2 volunteer SAR organizations and the Provincial Infection Control Network of BC (personal communications, PICNet).Thus, neither had official direct connections to channels of information that regularly provide infection control advice to the province's professional first responders and healthcare professionals.

Discussion
COVID-19 literature specific to SAR is not readily found through the usual literature indices.Koester reports finding pertinent results through Google Scholar but zero results searching PubMed, Ovid, and Web of Science. 8Koester's literature review documents similarities and differences among half a dozen SAR infection prevention guidelines from various agencies around the world for maritime, coastal, ground, urban, mountain, and cave rescue.Studies in several countries indicate frequency of rescue calls before versus during the pandemic did not change significantly.However, we are not aware of any previous studies reporting extent to which SAR teams were able to comply with infection prevention guidelines.
Infections caused by SARS-CoV-2 were first detected in Wuhan China late in 2019.In March 2020, the World Health Organization (WHO) declared a pandemic.Beyond infection precaution advisory documents issued by WHO and National Centers for Disease Control (from which SAR organizations can draw general advice), 2 international SAR associations issued their own guidelines specific to SAR operations.In April 2020, the International Maritime Rescue Federation released a comprehensive document, 9 and in March 2021, the International Search and Rescue Advisory Group released its guidance for urban search and rescue. 10arly in 2020, North American public messaging about recognizing COVID-19 cases focused on fever, cough plus recent contact through China travel. 6About that same time, postings from clinicians in Britain on the UK-based international Evidence-Based Health discussion list (https://www.jiscmail.ac.uk/cgi-bin/ webadmin?A0=evidence-based-health) described loss of sense of smell and taste as the prominent (sometimes exclusive) signs or symptoms in numerous cases already occurring there.An Italian mountain rescue group listed "Difficulty perceiving smells and flavors" in its 2020 checklist. 11Also, molecular epidemiology revealed that early SARS-CoV-2 isolates in New York predominately arose via Europe rather than Asia travel. 12Thus, from the outset, risk recognition within the biomedical community differed from risk recognition in North America's more public entities including SAR.Screening criteria used by SAR for risk recognition initially may have been too narrow.
Fortunately, in terms of risk mitigation, BC experienced among the lowest infection and mortality rates in the country and world throughout this pandemic (https://bccdc.shinyapps.io/covid19_global_epi_app/).This was, in no small part, due to targeted evolving precautionary measures introduced by a highly experienced Provincial Health Officer working closely with a prudent Minister of Health. 13Fewer initial cases in many parts of BC reduced relative exposure potential, and personal behavior precautions introduced (viz.social distancing, masking, hand hygiene, encouragement to not work while ill) increased personal safety for the general population and its workforces.Evidenceinformed periodic updates on the pandemic and its implications for precautionary measures were provided through daily television presentations by the Provincial Health Officer and Minister of Health; an information dashboard and weekly situation reports posted on government website (http://www.bccdc.ca/health-info/diseases-conditions/covid-19); popular news outlets frequently reflecting on the most recent briefings; guidance documents periodically issued by professional and other organizations and unofficial advice offered by various academic medicine specialists.Less trustworthy misinformation and opinion also abounded on social media.British Columbia Search and Rescue Association and RCMSAR based timely update releases on contextualizing reputable health department website information, and this study confirms their perceived value.
Several opportunities for improvement are evident from our exploratory study.First, most local volunteer SAR stations' criterion for selecting an N95 versus surgical mask for respiratory protection has not been consistent with the longstanding risk recognition and mitigation standard in hospitals that also was adopted by ambulance service paramedics.Second, why local stations have or need both latex and nitrile gloves is not clear.Third, among thousands of SAR volunteers, some local station members have first-hand experience with SAR operations as well as occupational expertise in chemical, biological, radiation, and/or nuclear hazards.Those would be particularly valuable on health and safety or first-aid committees, but neither BCSARA nor RCMSAR appears to have inventoried these qualifications at national or regional levels so may want to consider recruiting such members onto higher-level committees.Fourth, there appears to have been no effort on either side to create information linkages between the volunteer SAR first-aid setting and the provincial network for infection control professionals (PICNet).Provincial network for infection control professionals explained to us "PICNet's purview is to provide infection prevention and control guidance and support for health care settings, therefore, it would be outside of PICNet's scope to provide recommendations or guidance in non-healthcare settings."Infection control experts do provide advice for emergency health services professional responders employed in hospital emergency departments, and to ensure continuity to some extend that advice for ambulance service attendants who stabilize and transport patients to hospital.Some, as a professional courtesy, also occasionally provide police or firefighter groups with pertinent advice on infection risks and prevention practices.Infection control professionals should remember there are volunteer counterparts who could benefit from the same information provided to professional first responders.Fifth, a definitive review, documenting only 15 infections in 30 years, transmitted from administering CPR to millions, stated in 1998: "Recent research suggests that chest compression is more important in achieving adequate ventilation than mouth-to-mouth ventilation alone; in the future, rescue breathing may not be considered necessary for basic cardiac life support : : : " 14 More recent literature confirms compression-only CPR's effectiveness. 15The UK adopted compression-only CPR for volunteer SAR nationally. 16Since not everyone on search missions is likely to have at hand a bag-valve-mask (aka Ambu bag) fitted with virus filter, nor have maintained proficiency in its use, and probability of favorable outcome drops precipitously every minute high-quality CPR is delayed, compression-only CPR is a morepractical less-expensive SAR response.When supplemental oxygen arrives, either nonrebreather mask or bag-valve-mask can then be placed by someone wearing an N95 mask while administering high-flow rate oxygen. 9,10his exploratory study has several limitations.First, although we assume value rankings received from local stations are accurate regarding sources of information available to guide leadership decisions, we only requested participation of station leaders so did not poll all station members to confirm these are consensus opinions.Second, while it is likely that stations claiming to have both types of masks and gloves have them concurrently, given our crosssectional research design, it is possible that stations had only one type at a time sequentially.Third, geographic and size distribution of participating stations align well with the sampling frame (all stations) so can be representative; however, we have no way within the study to quantitatively assess extent of any non-response bias.

Figure 1 .
Figure 1.Perceived utility of various information sources.

Table 1 .
Proportion of stations equipped with personal protective equipment (PPE) items and how they were procured

Table 2 .
Extent to which stations had surgical masks and/or N95 respirators

Table 4 .
Criterion for selecting to wear surgical mask vs. N95 respirator

Table 3 .
Extent to which stations had latex and/or nitrile gloves

Table 5 .
Criteria among stations that reported having both surgical & N95 masks

Table 6 .
Timeline of infection prevention guidance document revisions and updates Encourages everyone to follow reasonable steps from Ministry of Health & BCCDC guidance to protect themselves and their group.Risk Mitigation: Advised to self-monitor health, use low threshold of suspicion, and be proactive about ordering cleaning, sanitization, or medical supplies.Training at discretion of group leaders; social distancing (1 m); and staying home if any symptoms of COVID-19 Hypertext links: http://www.bccdc.ca/health-info/diseases-conditions/covid-19 & https://www2.gov.bc.ca/gov/content/health/about-bcshealth-care-system/office-of-the-provincial-health-officer/currenthealth-topics/pandemic-influenza & http://www.bccdc.ca/healthprofessionals/clinical-resources/covid-19-care/clinical-care/firstresponders Addresses questions from SAR stations due to small crew space inside helicopters.Risk Mitigation: Eight bullet point items for planning helicopter operations emphasize screening, social distancing, and avoiding excess crewing.Lists 11 items to "sterilize" between flights.Hypertext links: Highlights BCSARA resource page & provincial selfscreening questions website.Increased exposure risk from travel & large groups, importance of appropriate surface cleaning products & techniques.Risk Mitigation: Prohibits face-to-face activities other than rescue taskings & essential maintenance; 70% alcohol added as alternative to bleach.Hypertext links: http://www.bccdc.ca/health-info/diseases-conditions/covid-19 Recognition: Reviews modes of transmission; answers volunteers' request for guidance on use of masks for respiratory protection.Risk Mitigation: Notes that BCSARA follows provincial guidance for health care workers & paramedics; gives specific advice on when who should wear masks, why N95, how to don & doff; discusses fit testing.Hypertext links: Cites BCCDC websites, BCSARA pages, and a YouTube video on how to don & doff an N95 mask.13 May Risk Recognition: Unchanged.Risk Mitigation: Reiterates previous instructions but allows face-to-face groups of 5 or less for maintenance, inspections and training to resume as of 15 May.Hypertext links: http://www.bccdc.ca/health-info/diseases-conditions/covid-19/prevention-risks/masks & https://www.cdc.gov/coronavirus/2019-ncov/specific-groups/people-at-higher-risk.html& https://www.healthlinkbc.ca/more/health-features/coronavirus-disease-covid-19& http://www.bccdc.ca/health-info/diseases-conditions/covid-19(Continued)

Table 6 .
(Continued ) Contains same sections as previous update.Risk Mitigation: Extends ban to all health regions, cancels HQ & RHIOT training until 2021, changes masking decision from station level to now require everyone on missions or during maintenance.Hypertext links: same as above.