Improving Health and Safety at Camps: AAP’s Policy Statement

Host: Hello, and welcome to Prevention and Protection, the United Educators risk management podcast. Today, Michael Ambrose, Founder and CEO of the DocNetwork, will speak with Melanie Bennett, Senior Risk Management Counsel at United Educators.

A reminder to listeners that you can find other UE podcasts, as well as UE risk management resources, on our website, www.ue.org. Our podcasts are also available on Apple Podcasts and Spotify. Now, here’s Melanie.

Melanie Bennett: Thank you. Michael, welcome to the podcast.

Michael Ambrose: Great to be here.

Bennett: We’re going to get more conversation about what you’re currently doing with camps and how you’re helping them. But before we do, I wanted to start back at the beginning. How did you get involved with camps in the first place?

Ambrose: It’s a great question. I’ve spent my entire life in the camp world. I grew up going to summer camp. I went to a camp in northern Ontario when I was a young kid. As I got older, I always found a way to get back to camp. The summer after I was graduated high school, I shadowed a family friend who was a pediatrician at a local camp in southeastern Michigan, where I grew up. I went up to the camp just to see what camp life and what life was like as a camp doctor. I ended up staying the entire summer I had such a great time.

This was a camp, it was not a camp for kids with special medical needs. It was a traditional residential summer camp. This camp was pretty well staffed. They had two doctors and three nurses on staff there in the pretty well run medical clinic. I witnessed, as a recent high school grad, that mistakes were being made all the time. There was process errors surrounding how medications were being administered, leading to medication errors. I had noticed that paper health forms, the camp doctor, the camp nurse wasn’t able to read or decipher the chicken scratch handwriting that families had written out serious medical concerns. Medical forms were being lost. I knew that there had to be a better way to improve the process and procedures surrounding camp health and safety.

I had approached the camp staff and the camp directors and said, “Hey, if you all are willing to buy a few laptops for the camp clinic, I’ll spend my freshman year of college writing some prototype software to improve process workflows,” and that was the kickoff and the impetus of my professional career into the camp world.

Bennett: One of the areas that I know you’ve been working on is this policy statement created in 2019 by the American Academy of Pediatrics (AAP) on improving health and safety at camp. How did you get involved with the AAP? How did they decide to create a policy statement about camps?

Ambrose: It’s a great question. After undergrad, my medical career progressed. I was premed and did my school at the University of Michigan. I then went on to medical school here in Ann Arbor and then completed a pediatric residency at the University of Michigan Children’s Hospital as well. Throughout my entire career and my medical education, I continued to find ways to get back to camp. It still exists to this day, but I had created some of the wilderness pediatrics rotation for medical students, and petitioned the Dean to let me get to camp for a month and just spend some time there, continuing to work and better understand the specific needs from health and safety standpoints as it relates to summer camp and when kids are away from home.

Part of it was twofold: I took two paths. While I was continuing my medical education, I was on one hand working on what became and is now DocNetwork, which is an electronic health records system dedicated to the health and safety of both kids attending summer camp and youth programs, as well as K-12 schools. We have the CampDoc and SchoolDoc products surrounding that. I dedicated my time and my free time to putting energy into the technology and process pieces to improve health and safety.

Then I began more on the medical- and policy-related side doing research and work with colleagues at the University of Michigan. Got introduced to those at a more national level to start working on researching policy surrounding health and safety at camp as well.

What we found was there are so many opportunities and so many areas in which kids attend camp. I think 20, 30 years ago, everybody assumed camp was this, maybe we saw in the movies, of you’re going away in the wilderness for four, six, eight weeks, sleeping in a sleeping bag in tents and going on canoe trips. But certainly, over the last decade, the concept of summer camp has transitioned a bunch. We have kids that may spend a week at a local summer camp, at a day program. They may go for another week or two to a camp in the Northeast. They may do a STEM-related program, they may do a dance- or arts-related program. The camps and youth programs are really happening in so many different areas.

I became, as I finished my medical career and my medical education, I became a member of the American Academy of Pediatrics. The AAP is a national governing body that is setting the standard of care and advocating for children across the country and across the globe. They are the ones who are setting policies and recommendations on everything from food recommendations and nutritional recommendations, to seatbelts and car seat safety, to vaccine recommendations. For those who have kids or are caring for kids, all of the recommendations and guidelines that you follow are typically being set by the American Academy of Pediatrics.

The American Academy of Pediatrics puts out what they call policy statements about every five years. Policy statements are, again, recommendations and standards of care set by this governing body. They have policy statements from all the things that you would typically think about. Vaccines, car seats, seatbelts, nutritional recommendations, mental health, behavioral health, head injuries. They have policy statements on the prominent and prevalent things that occur in children in their everyday lives.

One of the policy statements that they’ve had for quite a few years now is a policy statement surrounding the health and safety of children at camp. Every five years, this document gets updated. I was tapped by the AAP to rework what is now the most recent policy statement that was put out in 2019. We are currently working on an updated statement as we speak, having frequent meetings with my coauthors and the team to rework it, that we hope will be released within the next year.

Bennett: We’re going to link the 2019 statement to the webpage for this podcast. What are some of the highlights for you?

Ambrose: Yeah. When the policy statement came out in 2019 shortly before the COVID-19 pandemic, while we certainly weren’t predicting anything, the policy statement talked about a lot of things, and we can dive into some of the key and significant updates from the prior policy statement. The significant things, the most significant was surrounding vaccination and vaccines, we talked a little before about that. There was a lot of recommendations surrounding epinephrin and EpiPens and food allergies. There were recommendations surrounding communicable diseases. That is obviously quite relevant over the last few years and still relevant today. Again, other recommendations on medications, allergies, and general health history, and we can dive into that a little bit.

One of the biggest changes from the American Academy of Pediatrics was the scope of who this policy statement applies to. In prior versions of this policy statement, it was really geared and guided for, again, what you would think of as a traditional summer camp. A traditional residential sleepaway or day program. Now, as over the last decade the concept of summer camp and youth programs has changed, the policy statement specifically calls out programs that are being run in parks and rec facilities, programs that are being run on college and university campuses. Programs that are being run on K-12 school campuses as well. This is now a standard of care and the guidelines, whether you’re aware of it or not, it is very important that schools, colleges, universities, really anyone running a youth program is aware of the guidelines that they should and need to be following.

Bennett: I’m going to keep going on that. We have a lot of K-12 schools, higher ed colleges and universities listening, people who work at those schools and colleges and are running camps. Which parts of the statement do you think are particularly relevant to them?

Ambrose: Yeah. The policy statement talks a lot about the pre-camp assessment. I talk a lot about, in educational talks and sessions that I give, is that we always want to talk about setting the kid up for success. We want to make sure that the camp is a good fit before that child arrives. That means opening up the dialogue with the families that you are serving the kids that you are serving well before the first day.

The American Academy of Pediatrics talks a lot about evaluating not just the child’s physical health if it is a basketball camp, or a football camp, or a sports-related program, making sure that they understand the strenuous nature of that program. But also, making sure that you understand the mental and emotional readiness before selecting a camp. If this is a residential camp that is far away, we see a lot in higher ed, they are taking kids and children from out of state or sometimes out of the country, making sure that that child is ready and understands the basic needs and functions that they have to have in order to be successful. Really making sure that there’s alignment between the child’s needs and the camp’s offerings.

One last thing I’d love to add. When we talk about that pre-camp assessment, we’re talking about physical health, mental health, emotional readiness before that child attends camp. There’s a few examples to this. If you have a child who was recently diagnosed with diabetes and they are really starting to figure out their insulin regimen and blood sugar checks, you want to make sure that you have a conversation with that family and that child before they arrive on day one. And make sure you’re equipped and that you have the appropriate nursing staff, or counselors, or access to the right supplies in order to meet the needs of that particular camper. You don’t want to find out on day one or after the family has dropped that child off that there is something that you’re not equipped or ready to handle.

Again, you may not be able to accommodate every particular camper, but you want to make sure you’re having those dialogues and those conversations well in advance. That means collecting that information and starting that dialogue through a detailed health record that is capturing medical history, vaccination status, special medical needs. Does the child have a history of diabetes, asthma, sickle cell disease, epilepsy? It’s not just collecting the information, and that’s a lot of the concerns that I see when I’m consulting or advising camps. They may be checking the box where I’m just capturing the information, families are filling out a standard health form. But the data is only good and helpful if the camp programs review it and take the time to evaluate that information.

If you are going to promote your program as a peanut-free or a peanut-aware program, you want to make sure that you have the right processes, protocols, procedures in place to make that claim and make that stance. You want to evaluate and see which of your campers have a history of peanut allergies. Who are bringing their epinephrine auto-injectors, their EpiPens to camp with them? Does the camper know how to self-administer that particular device? Making sure that we’re well aligned prior to that child’s arrival is critical.

Bennett: I’m going to repeat what you just said because it’s a great point. It comes up in risk management so often and this is a particular area where it’s particularly important. Don’t just collect the information — make sure you’re going through the information and responding to it.

When you were talking earlier about the 2019 statement, one of the interesting things that you mentioned is the statement came before the pandemic, before the COVID pandemic. And yet, the statement specifically talks about pandemics and epidemics as a common concern for camps. What preventative actions should camps take in relation to these risks?

Ambrose: Yeah. There’s a few things here. The first — and it’s very interesting, we’re seeing it again and very timely in the news right now — that block of a few years during the COVID-19 pandemic, we forgot quite a bit what was happening right before that. If you recall and go back, and maybe look it up on Google, we were dealing with a measles outbreak in that particular summer. There was a lot of focus and attention, and camps and youth programs across the country were running into concerns about vaccination status, measles risk exposure. We had been spending some time evaluating that, looking at vaccination policies at particular camps. We had come out and put out recommendations specifically to vaccines, immunization policies.

The COVID-19 pandemic then happened, and the focus obviously turned to that. But the work that we were doing prior to that, we had outbreaks, infectious disease outbreaks at camps for decades. That might be flu, that might be a gastrointestinal or stomach virus that might be happening. We’re certainly and the public is certainly much more aware of infection control measures and communicable diseases because of the COVID-19 pandemic, but this is something that has been happening at summer camps since they started. When you put a bunch of kids or a bunch of people in close proximity together, the risk for infections spreading grows quite significantly.

There are obvious recommendations in this policy statement that talk about general infection control measures. It talks about pre-screening. Making sure that, when a child arrives at camp, that they are healthy. There are recommendations from both the American Academy of Pediatrics and the American Camp Association that talk about evaluating the health and status of a child when they arrive. We think about the camp world, the lice checks, checking everybody’s heads when they arrive, but it’s much more than that. It’s making sure nobody has a fever. Maybe making sure nobody has any infectious symptoms. Coughs, rashes, vomiting, diarrhea, things that might be concerning once they enter the camp community and bubble, and evaluating that before we introduce that particular child.

In addition and probably the most significant update from the policy statement when it was released back in 2019, were recommendations surrounding vaccines, immunizations in children. The concept of vaccine hesitancy and concerns about children being vaccinated is something that is prevalent in today’s society and has been for a while. But the American Academy of Pediatrics stands pretty firmly on this, that every child should be fully vaccinated prior to their arrival at camp. I’ve personally done, with some of my former colleagues and work with some others in the medical community, research surrounding vaccines and vaccine-preventable illnesses at camp. You would be shocked to find out that every summer, there are things like outbreaks of mumps and flu and chicken pox at summer camps because we have children attending camps that are not fully vaccinated.

For the very first time from the American Academy of Pediatrics as it relates to youth programs and summer camps, the AAP has come out and said that all children should be fully vaccinated and that nonmedical exemptions to vaccines are considered inappropriate for ethical and public health reasons. That’s a pretty strong statement, and for some might generate a little bit of controversy and emotion. However, this is considered the standard of care from the American Academy of Pediatrics.

This does not mean children who have medical exemptions ... If I am a child who just finished chemotherapy for leukemia and I may not be eligible for certain vaccines, those exemptions are still absolutely appropriate, and we wouldn’t want to limit a child’s ability to participate in a youth program because of it. Per the American Academy of Pediatrics, nonmedical exemptions are inappropriate, and all campers and staff, I referred to just campers before, but this really applies to everybody attending camp, should be fully vaccinated to reduce risk for the people health and safety. A quite important step in that direction.

This is all quite relevant now and timely as we are seeing the measles outbreak pop up again in a handful of states, starting in Texas, New Mexico, and the South. About a month or so ago, we started seeing measles cases ramp up. We absolutely believe that this isn’t going anywhere and we will have camps dealing with the concerns surrounding measles outbreaks this summer. Again, recommendations from the American Academy of Pediatrics are front and center again, certainly as it relates to vaccines and making sure kids are protected.

Bennett: The measles issue is a major issue that will continue. Are there other emerging risks camps should be watching?

Ambrose: Yeah, it’s a great question. Front and center right now is feedback and recommendations surrounding not just heat illness and heat safety, but air quality as well. We have seen a prominent increase in the number of wildfires happening throughout this country. While previously, we were seeing those typically just on the West Coast, maybe out in California. Many of those surrounding states have created policies or procedures to deal with the wildfires, and smoke, and poor air quality that might be happening during those times. We’re seeing that start to spread. Even here in Michigan two years ago, when there were some of the wildfires in Canada, we were having the impact and the smoke was coming down into Michigan. Michigan camps had never dealt with wildfires or air quality issues previously.

There’s a lot of upcoming research and recommendations from the American Academy of Pediatrics, from the American Camp Association, and the Alliance for Camp Health on starting to establish best practices and policies for poor air quality.

One of the biggest recommendations is finding a solid source for what is called AQI or the Air Quality Index, to measure when quality is poor, when it is OK, and what the impact of is on children. Finding a source, creating policies and procedures well in advance. All of the recommendations, whether it be on vaccines, on mental health, on physical health, setting up a child with asthma, or diabetes, or epilepsy up for success, it’s all about the pre-camp preparation. So that when something happens, you are ready to go and you are not scrambling to come with an answer while the fire is burning.

As it relates to air quality and wildfires, making sure that you have policies and procedures in place. If the air quality, the AQI level is at a particular level, what is your practice here? Do you move all activities indoors? Do you have children mask? What happens if in your particular instance, if you don’t have a filtered air conditioning system in the building that you might be using? Keeping a closer eye on kids that are at higher risk. Especially with air quality, we worry most about kids with asthma or seasonal allergies. They may have a higher risk of having an exacerbation of their symptoms, so making sure that staff are trained and well aware of keeping an eye on those particular kids. I’d say that’s probably the hottest topic that we’re keeping our eye on right now.

Bennett: Let’s end our conversation today by talking more about the resources that are available for people who are running camps.

Ambrose: Yeah.

Bennett: Can you talk more about the work that you do to assist camps and what great resources are out there?

Ambrose: Absolutely. The first recommendation I would give is start by reading the American Academy of Pediatrics’ national policy statement on improving health and safety at camp. This is the standard of care. We worked very closely with the American Camp Association, with the Alliance for Camp Health, and with other governing bodies to put this document together. It is a free document, you should read it. There’s no expectation that on day one, you will be following every single guideline, but making sure that you are making steps and moving in that right direction. That continuous quality improvement is so important.

I’d also recommendation looking at the American Camp Association. Whether or not your camp is accredited by the American Camp Association, they too are setting standards of care, and guidelines, and recommendations for camps. They have some great guidelines out there as well.

We collaborate very closely with the Alliance for Camp Health. They’re a fantastic resource to join. They have so many free resources and free opportunities. To join as a member is very economical, a very good investment. They’re available to point and guide you in the right direction.

Outside of that, there’s two other groups certainly in the higher ed space that I would recommendation. There’s one called HEPNet, Higher Education Protection Network. They do a wonderful job and have a fantastic community of individuals running youth programs on college and university campuses. I work and work quite closely with them as well. Then through the American Camp Association, they have a group called Camps on Campus. This is not just for higher ed, but for K-12 as well. A great community and a great resource for questions or concerns you might be having.

My biggest advice and the recommendation I always give when I meet somebody for the first time who is struggling, or looking for help, or looking for resources is crowdsourcing. You are not the only one having the same problem, the same concern. Through some of the groups that I mentioned, if you poll the audience and ask, this community is so tight-knit that they are so willing and able to help. Share their guidelines, share scenarios that they’ve had happen. Connecting with that community is fantastic.

Bennett: Another resource that you have is CampDoc. Can you tell me a little bit more about what that is?

Ambrose: Absolutely. CampDoc is an electronic health record, online registration, and compliance tool designed for youth programs. We work with hundreds of higher ed institutions, as well as K-12 schools throughout the school year and those running youth programs. Really designed to improve the health and safety of kids when they’re away from home.

Bennett: That’s it for today’s podcast. Thank you, Michael, for joining me today.

Ambrose: Great to be here. Thank you so much.

Host From United Educators insurance, this is the Prevention and Protection Podcast. For additional episodes and other risk management resources, please visit our website at www.ue.org.